Sure Start
	 — 
	Question

Lord Dubs: To ask Her Majesty's Government how many Sure Start centres have been closed since the Coalition came into power; and how many have had their funding cut in real terms.

Lord Hill of Oareford: My Lords, there were 3,631 children's centres in April 2010. Information supplied by local authorities shows that as of 8 September 2011, there were 3,507 children's centres in England. Of the reduction of 124 children's centres, six are outright closures; the remainder are accounted for by local reorganisations such as the merger of two or more centres. A breakdown for each local authority has been placed in the Library and is available on the department's website. The department does not hold information on local authorities' funding allocations to individual children's centres.

Lord Dubs: My Lords, will the Minister confirm that after the coalition was elected, the Government gave an undertaking that Sure Start centres would not be cut? What we are seeing in the Minister's Answer is the first of a wave of cuts. Is it not right that estimates now suggest that up 250 centres will be closed within the 12 months and that the position is getting worse year by year?

Lord Hill of Oareford: My Lords, I have given the noble Lord the snapshot of figures that we have for September. As I said, that shows that there have been six outright closures and a further 120 or so mergers. If one added all those together and accepted that those were all closing, which they are not, that comes to something like 3 per cent of the total of Sure Start children's centres. It is the case that the Government attach high importance to the role that Sure Start children's centres play, which is why through the early intervention grant we have put in the funding to maintain a national network of Sure Start children's centres.

Baroness Walmsley: My Lords, when my honourable friend Sarah Teather, the Minister for Children, made her announcement this morning about the additional free early years places for disadvantaged two year-olds, I noticed that there was something in the consultation about information for parents. The idea is one of moving to an annual report from local authorities about the sufficiency of places, rather than the current assessment. Can my noble friend the Minister say how he feels that this new system will be better than the old one?

Lord Hill of Oareford: My Lords, the point of having much more information available to parents is that we hope that that will empower them to have more say in the system. We are also looking at trialling payment by results in Sure Start children's centres, which we think will lead to better services, targeted more on those suffering from the greatest disadvantage. This approach will, I hope, improve the quality of the services delivered through this vital part of early years provision.

Baroness Howarth of Breckland: My Lords, does the Minister agree that there is some correlation between the removal of a number of preventive services at local authority level, Sure Start centres being one, and the rise in the number of children who are coming before the courts? This October, a record number of children came before the courts and then went into care. Do the Government not have a view about the need for local authorities to continue to improve their preventive services to keep children with their families rather than having the high level of removal that is happening at the moment?

Lord Hill of Oareford: I agree on the importance of that. We must do all that we can to try to keep families together and children with their families. That strikes me as being vital and that is one reason why the Government are looking at ways of trying to trial more support for parents, looking at ways of putting extra funding into Relate to keep families together and, more generally, looking at the whole adoption system and the range of support that we make available for children. However, I agree with the noble Baroness about the importance of that.

The Lord Bishop of Bath and Wells: My Lords, 83 per cent of all Sure Start centres are facing budget cuts. Of these the worst hit, in Hull, faces a 56 per cent cut. Does the Minister agree that the cuts affect children, many of whom belong to families being helped out of poverty by the Sure Start provision? Does he further agree that by failing to require local authorities to ring-fence Sure Start, it has become a soft target for cash-strapped authorities?

Lord Hill of Oareford: I do not agree with the last point made by the right reverend Prelate. I hope the figures I was able to announce to the noble Lord, Lord Dubs, demonstrate that local authorities are working extremely hard to spend the money they get through the early intervention grant and maintain the important services delivered through Sure Start children's centres. Of the 152 local authorities, I think I am right in saying that 119 have announced no change at all to the number of Sure Start children's centres that they have; of the others a range of measures has been taken. The point of doing away with the ring-fence is to give local authorities greater responsibility and we think that is the right approach.

Baroness Hughes of Stretford: My Lords, for the first time ever we have the prospect, through Sure Start, of a universal integrated service for the under-fives and their parents. It is clear, however, that local authorities are not only closing centres but are cutting their budgets dramatically-11 per cent this year, 21 per cent next year-in response to the Government's significant cuts in the early intervention grant and the removal of the ring-fence, referred to by the right reverend Prelate. Will the Minister accept that it is the responsibility of Government to ensure that this universal service continues instead of passing the buck to local authorities and that every parent has the right to access Sure Start? Will he at least consider bringing back the ring-fence for Sure Start funding?

Lord Hill of Oareford: As I explained in my answer to the right reverend Prelate, there is a difference of opinion between us and the party opposite about the ring-fence. It is our view that giving local authorities greater discretion over their budget is the right way to go forward; to treat them like the responsible bodies that they are. I recognise there is not as much money around as there was before-I cannot deny that that is the case-but we believe the right way is to put the same funding into the EIG for Sure Start children's centres, which are an extremely important service. We want to focus them on providing better services for the most disadvantaged and we think that is the right way forward.

Lord Campbell-Savours: My Lords, does it remain the policy of the Government to retain ring-fencing of any area of local expenditure, over which the noble Lord has some influence?

Lord Hill of Oareford: My Lords, I fear I have not boned up on the whole approach towards ring-fencing expenditure across local government. So far as my department is concerned, the general direction of travel we want to go in is to simplify funding, to have as few separate grant streams as we can and to delegate responsibility as much as possible, whether that is to local authorities or to individual schools.

Food: Prices
	 — 
	Question

Lord Knight of Weymouth: To ask Her Majesty's Government what measures are being taken to assist families in the United Kingdom to cope with increasing food prices.

Lord Taylor of Holbeach: My Lords, the impact of rising food prices is of concern to the Government. While it is not the Government's role to control food prices, we understand the need to monitor the impact of price increases on households. I hope it reassures the noble Lord that the Government provide a nutritional safety net to extremely low-income families through the Healthy Start scheme, which offers vouchers for essential foods. As the noble Lord will know, we also take into account food prices when benefits rise annually with consumer price inflation.

Lord Knight of Weymouth: My Lords, according to the latest statistics from the OECD, UK food consumers face the second highest increase in food prices of anywhere in Europe-ironically, after Hungary. What are the Government going to do about it? Why are British food consumers so hard-hit relative to others in Europe? This is an urgent problem for family budgets-what is the Government's response?

Lord Taylor of Holbeach: My Lords, the House will know that food supplies and volatility in food price markets have been a feature of the past 12 months. We cannot doubt that in this country we have the most efficient food supply chain in Europe. Our supermarkets are extremely price-competitive, as anyone here who has shopped in other countries will realise. I think that the noble Lord was talking about increases rather than absolutes, but I am talking in absolute terms. Of course we are concerned. I think that the secret lies in increasing food production and producing a great deal more self-sufficiently in this country-a policy that was abandoned by the last Government but which this Government are determined to take up.

Lord Howe of Aberavon: I dare say that my noble friend will not recall that my first appearance in the Cabinet was on Guy Fawkes Day 1972, when I was appointed Britain's first Minister for Consumer Affairs-a role described by Sir Edward Heath as the Minister for Keeping Down Prices. Does my noble friend recollect that that task was then taken on by the noble Baroness, Lady Williams of Crosby, and that the most enthusiastic enforcer was the late Lord Cockfield? If there is any lesson to be learnt, it is that we were all wasting our time and burdening the nation to wholly no good. Will he please assure us that that lesson is fully understood?

Lord Taylor of Holbeach: I am very grateful to my noble and learned friend for taking me back to my childhood in politics-names like Aubrey Jones and Fred Catherwood and prices and incomes policies all come back to me. Indeed, my noble and learned friend is right to remind us that there is nothing like a competitive market with a strong retail sector to make sure that prices are kept as competitive and as low as possible.

Lord Pearson of Rannoch: My Lords, can the noble Lord confirm the previous Government's estimate that the EU's agricultural policy costs each family of four in the United Kingdom about £1,000 per annum in higher food costs and tax? Would he also agree that since these higher food costs fall largely on milk, bread and sugar, they hit our poorest hardest? Finally, would he confirm that there is nothing we can do about this while we remain in the European Union?

Lord Taylor of Holbeach: I should inform the noble Lord that in actual fact the world price of sugar is currently higher than the internal European price of sugar. Indeed, the common agricultural policy, despite all the misgivings, at least provides some degree of stability in the huge volatility that there has been in global commodity prices. I cannot share the noble Lord's view.

The Lord Bishop of Norwich: My Lords, is the Minister aware of the rapid growth of food banks around the country-a Christian initiative which is gaining ever wider support? I declare an interest as the patron of Norwich Foodbank, which has assisted 860 families and individuals in just the past three months. What might be done to better integrate this generous voluntary provision with the work of statutory agencies?

Lord Taylor of Holbeach: Last week I, like a number of other noble Lords, attended an evening on food waste here in the House. Present at that gathering was FareShare, which, with FoodCycle, offers a facility whereby food that would otherwise be wasted can be made available through charity outlets. I think that that is a worthwhile initiative, and I congratulate my noble friend Lady Jenkin of Kennington on arranging the evening. It was most enlightening and, indeed, encouraging.

Baroness Trumpington: Is the Minister aware of the extremely helpful programme going out weekly on the BBC describing British food that is available to everybody but does not seem to be taken up? Can Defra please help the BBC? Cabbages, eggs and everything you can think of are being dealt with most efficiently on the BBC-I hate to give it credit but it is true. It would be helpful if Defra could follow in those valuable footsteps.

Lord Taylor of Holbeach: The BBC has pioneered informative broadcasting on agricultural matters, from "Farmer's Diary" to "The Archers" to "Countryfile", all of which I hope inform the public about what it is to produce food and all the elements that go in to making a strong food supply chain in this country.

Health: Cancer Drugs Fund
	 — 
	Question

Baroness Morgan of Drefelin: To ask Her Majesty's Government what assessment they have made of the effectiveness of the cancer drug fund.

Earl Howe: My Lords, since October 2010, more than 7,500 patients in England have benefited from the additional funding we have provided for cancer drugs. The £600 million we have committed over three years will improve the lives of many thousands more cancer sufferers, giving them precious extra time with their loved ones.

Baroness Morgan of Drefelin: My Lords, I remind the House of my interest as chief executive of a cancer research charity. Can the Minister share with the House thoughts on plans for the fund, following the abolition of strategic health authorities which are currently responsible for administering the fund? Will he share with us any thoughts the department has about emerging patterns of variation in access to the fund? I appreciate that it is a new fund and that patterns are difficult to see in a field where there are small numbers. I would, however, be interested to know what steps the department is taking to issue further advice on that question.

Earl Howe: My Lords, I pay tribute to the noble Baroness for her work in this area. She asked what would happen when strategic health authorities are abolished. Arrangements from 1 April 2013, which is the planned abolition date, and beyond will be the subject of discussions between my department and the NHS Commissioning Board Authority. So I cannot give her definite news yet on that front.
	I know that the regional clinical panels are using their own judgment to come to decisions, and it is entirely right that they should. At the same time, they are alive to apparent variations in the drugs that are being made available through the fund in different regions, and I understand that the SHA clinical panels are working collectively now to better understand the reasons for those differences.

Lord Clement-Jones: My Lords, I welcome the fact that thousands of cancer patients have benefited from the cancer drugs fund, but can the Minister give an assurance that those cancer treatments currently available through the fund will continue to be available when value-based pricing is introduced in 2014?

Earl Howe: One of our aims for value-based pricing is to give patients better access to innovative and clinically effective drugs, which, unfortunately, has not always been the case until now, hence the need for the cancer drugs fund. That is certainly one of our ambitions for value-based pricing.

Baroness Pitkeathley: My Lords, does the Minister agree that one of the problems with this very welcome fund is that still too few patients know about it? Is his department planning any information campaign to ensure that patients know more about it so that they can ask for access to the fund themselves, particularly in view of the more complex structure that they will face in the NHS when the Bill currently before the House is law?

Earl Howe: My Lords, the noble Baroness makes a good point. We endeavoured to publicise the fund in April when it was created. We have reminded the health service to make the fund's existence known wherever possible. The specific answer to her question is no, we do not plan a publicity campaign. However, we wish to ensure that clinicians in the service are as fully aware of the fund as they should be. I believe that they are, certainly at the level of secondary care.

Baroness Gardner of Parkes: My Lords, I have read in the paper that some very expensive cancer drugs will now be approved by NICE on the understanding that DNA testing will assess whether the patient will benefit from them. This was one of the arguments to do with giving terribly expensive drugs. Will these drugs also now be available from the same source after 2013?

Earl Howe: We plan to ensure that value-based pricing will take care of the gap that currently exists in the availability of cancer drugs, which the cancer drugs fund is trying to address. In theory, until then any drug that a clinician wishes to prescribe for a cancer patient is available under the cancer drugs fund. There is no restriction that we have set; it is a clinical judgment.

Lord Roberts of Llandudno: My Lords, many patients from north Wales go to Christie's Hospital in Manchester or Clatterbridge on Merseyside. How will this fund be available to them? How does Wales come out of the complexity of this situation?

Earl Howe: My Lords, it is of course for the devolved Administrations to make their own decisions about their individual needs and budgets. It will depend on whether commissioners in Wales are willing to accept the cost of treating a patient with a drug that is not normally available in Wales. I cannot generalise but it is up to Welsh commissioners to take that decision.

Baroness Howarth of Breckland: My Lords, I am aware that 2013 is approaching very fast. Does the Minister's department have a timetable for the strategy that will be in place once the strategic health authorities have gone? Will there be consultation on those plans?

Earl Howe: My Lords, as I told the noble Baroness, Lady Morgan, discussions are ongoing as to the arrangements that will be in place after the abolition of strategic health authorities. I cannot say that we have definite plans in place but I hope that we will be able to announce our plans soon.

Baroness Farrington of Ribbleton: My Lords, cancer treatment drugs are often used in a range of measures to treat people suffering from cancer, including both chemotherapy and radiotherapy. Is it not the case that concern is being expressed about the closure of access to radiotherapy in some hospitals, and that people are having to travel for up to three hours? I understand that this is a problem in Essex and other parts of the country. Does the Minister share the concern about people not being able to get the treatment they need if these centres close? Who is responsible now, and who would be responsible in the future under the Government's proposals, for ensuring that reasonable access is maintained?

Earl Howe: We are concerned to ensure that patients have reasonable access to the treatments that they need, including radiotherapy. I can tell the noble Baroness that part of the additional funding that we are making available under the strategy for cancer that we published earlier this year will go towards widening access to radiotherapy-not only better utilising the facilities that we have but commissioning new facilities. However, I am afraid it is the case that we increasingly see specialised units being concentrated in fewer locations. Unfortunately, this will mean that some patients have to travel a little further than they otherwise would have.

Media: Ownership
	 — 
	Question

Baroness Scotland of Asthal: To ask Her Majesty's Government, in the light of the recent News Corporation bid for full ownership of BSkyB, what assessment they have made of the legislation relevant to the bid; and what deficiencies in the legislation they have identified.

Baroness Rawlings: My Lords, the News Corporation bid for BSkyB raised a number of issues in respect of the existing media ownership regime. The Secretary of State will consider these issues, alongside any others and the recommendations from the Leveson inquiry, as he undertakes the communications review.

Baroness Scotland of Asthal: My Lords, does the Minister accept that there is general concern across the House about the adequacy of the current legislation? Does she also accept that the provisions of Section 58(3) and (4) of the Enterprise Act were created to enable the Secretary of State to amend the conditions in Section 58 if he or she felt that the need arose? In those circumstances, will the noble Baroness tell us why the Secretary of State refuses to take advantage of Section 58(3) and (4) to ensure that in future, if there is a fundamental mistake, misrepresentation or act of bad faith, advantage cannot be taken of the same?

Baroness Rawlings: My Lords, yet again the noble and learned Baroness raises a very technical and important point. This follows our extensive correspondence about Section 58(3) and (4) of the Enterprise Act 2002, all letters relating to which have been placed in the Library. With all due respect to the noble and learned Baroness, Lady Scotland, we may not agree on specific points, but I want to clarify that there is already a requirement on Ofcom to make certain that anyone holding a broadcasting licence is and remains a fit and proper person. I again stress that this is an ongoing requirement and not one limited just to a merger situation. I am most grateful to the noble and learned Baroness for raising this important point again and we will consider it. The Secretary of State is not refusing to act; he will bring this up at the Communications Bill committee while also awaiting the results of the Leveson inquiry.

Lord Fowler: My Lords, does my noble friend agree that over the past 10 years, and way before that, Governments and media owners have become far too close to each other? Would it therefore not be sensible to ensure that Ministers do not make the final decisions in media takeovers?

Baroness Rawlings: My noble friend makes a very good point. He has brought it up before and he knows that the Secretary of State agrees with it. The Secretary of State said this in his speech in Edinburgh on the Royal Television Society. He said that he wanted to explore this option in more detail and welcomed any views. At the same time, he will take into account the recommendations of the Leveson inquiry before making any final decisions. This is on the table and I am pleased that my noble friend has brought it up.

Lord Razzall: My Lords, obviously this is an occasion on which we are slightly intruding on private grief, bearing in mind the travails of News Corporation. Does the Minister not agree that the concern at the time of the original bid was that, if the merger were allowed, there would be no further power for either Ofcom or the Competition Commission to intervene, even if the News Corporation share of the market got bigger and bigger? Does she accept that there is an opportunity in the future Communications Bill to ensure that intervention can take place not just when there is an act such as a merger or a takeover but at any stage thereafter if the organisation gets too big?

Baroness Rawlings: My noble friend is very expert in these matters and has gone to the core of the subject. We are looking at the existing rules, particularly in the light of the News Corporation merger. It is important that these rules that we have in place do not allow one person or organisation to have too much control over the whole media landscape. We want a vibrant media market which attracts investment, ideas and skill. The challenge is to come up with suitable restrictions on media ownership which do not unduly restrict those. We recognise the gap that he mentions.

Lord Prescott: My Lords, the noble Baroness will realise that in the debates that we have had in this House on the Murdoch press and its application to BSkyB she has constantly told us that it is an issue not of criminality but of plurality. However, those crimes have continued under Murdoch. Indeed, only four months ago the Secretary of State for Culture assured us that he had interviewed Murdoch and was satisfied that he was increasing the independence of the editorial board and the financial viability of BSkyB. I hope the Minister will understand that it is not acceptable for this company to be in control of BSkyB or, indeed, to own the shares that it has at the moment as it is not a fit and proper company. Will its present shares be now reconsidered as the company is not a fit and proper one in view of all its criminal activities?

Baroness Rawlings: My Lords, I understand the concern of the noble Lord, Lord Prescott, and how he has suffered in this matter. We acknowledge that so far one newspaper in particular was responsible for the hacking and that it was the solid investigative journalism of another that exposed it. I am sure he agrees that we need to restore public trust in the regulation and activities of all our newspapers, and we expect that newspapers on the whole will welcome this. We trust that the Leveson independent inquiry will be able to do this and we trust in self-regulation in the capable hands of my noble friend Lord Hunt of Wirral.

Al-Qaida (Asset-Freezing) Regulations 2011
	 — 
	Motion to Approve

Moved By Lord Sassoon
	To move that the draft Regulations laid before the House on 11 October be approved.
	Relevant documents: 29th Report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 9 November.
	Motion agreed.

Health and Social Care Bill

Main Bill page
	19th Report from the Delegated Powers Committee
	18th Report from the Constitution Committee

Committee (5th Day)

Relevant document: 19th Report from the Delegated Powers Committee, 18th Report from the Constitution Committee.
	 Moved by Earl Howe
	That the House do now resolve itself into Committee.

Baroness Thornton: My Lords, I rise to intervene at this stage because I think this is the only place where I can ask the Minister about an important matter concerned with the ability of the House to conduct a comprehensive consideration of the Health and Social Care Bill.
	On Friday last week my honourable friend John Healey MP made available the report that he had received from the Information Commissioner. What he asked for a year ago was the risk register which would have set out the key risks with information about them and an assessment-RAG, which is the traffic lights system-of their likelihood and impact on the implementation of the Bill through the transition period. His request was initially refused and has gone to appeal. Noble Lords will realise that this information is completely pertinent to the further consideration of the Health and Social Care Bill in Committee here. The issue I seek clarification on is the very damning judgment of the Information Commissioner. He says that the Department of Health must disclose this information within 35 days of receipt of his notice. Were the Secretary of State to wait until the last possible minute, this would take us near to the very end of our Committee stage on the Bill. In the spirit of open and transparent government, I ask the Minister to make the information available to the House as soon as possible, and certainly in time for consideration of the Bill on Wednesday morning at 11 am.
	The risk register is available immediately because it is a regularly updated component of good governance of any major programme, and as such can be easily accessed. In other words, it is not a difficult document to duplicate or forward to anyone. The commissioner finds that there is a very strong public interest in the disclosure of this information given the significant change to the structure of the NHS proposed by the Government. I hope that the Minister will be able to assist the House by making this information available very quickly because I am sure he will realise its relevancy. I hope very much that I will not find myself back here on Wednesday morning asking why the release of this documentation has not been possible. I regret that, under those circumstances, I may be asking what the implications for the future consideration of the Bill might be if the House does not have access to this potentially very important information.

Baroness Williams of Crosby: I hope that the Minister will give very careful consideration to this request. I believe it will enrich our debate substantially and of course enable us to deal with issues that may change as we learn more about the effect of these statements. I plead with him on behalf of these Benches to consider whether the department could release these documents as quickly as possible.

Earl Howe: My Lords, I am grateful to the noble Baroness for giving me prior notice of her question. I am grateful too to my noble friend Lady Williams for her remarks. As I stated in my letter to Mr John Healey some time ago, I am of course conscious that there will be public interest in the contents of the risk register. However, from a government perspective, we need to balance this with the public interest in preserving the ability of officials to engage in discussions of policy options and risks without apprehension that suggested courses of action may be held up to public and media scrutiny before they have been fully developed or evaluated. We also need to balance the need for my ministerial colleagues, our officials and I to have sufficient space in which to develop our thinking, explore policy options, and weigh all this against the risk that disclosure may deter candid discussion in the future, which may in turn impact on the quality of decision-making. Those are the issues.
	We are therefore currently considering the decision notice from the Information Commissioner. We have to respond by 6 December and we intend to meet that deadline. Unfortunately, I cannot go beyond that commitment today. In the mean time, it is perhaps right for me to point out that we have already made public a very considerable amount of detail about our reforms, including information on key sensitivities and risks by policy area in the impact assessments that were published in January and September this year. I refer the noble Baroness to these documents. In addition, we continue actively to engage with stakeholders, building on the work of the NHS Future Forum and listening exercise.
	Motion agreed.
	Amendment 46
	Moved by Lord Patel of Bradford
	46: After Clause 5, insert the following new Clause-
	"Secretary of State's duty as to promoting equality of provision
	After section 1D of the National Health Service Act 2006 insert-
	"1E Duty as to promoting equality of provision
	In exercising functions in relation to the health service, the Secretary of State must have regard to the need to promote equality for those providing services on behalf of the health service and shall within one year of passing this Act, lay a report before Parliament on the treatment for Value Added Tax of supplies by charities to bodies exercising functions on behalf of a Minister of the Crown of healthcare services or associated goods."

Lord Patel of Bradford: My Lords, we have discussed many aspects of equity and equality in relation to this Bill. In moving this amendment, I wish to draw attention to one matter that concerns the equity of provisions for VAT. Noble Lords will be aware that certain organisations, such as the NHS and charitable organisations, have particular exemptions in respect of VAT. I am not an expert in this area and certainly would be keen to hear from those noble Lords here today who are.
	It was only in January this year that we debated the unfair burden placed on charitable organisations that take on public services but cannot claim the same VAT exemptions as the health service providers they have succeeded. A major inequality exists with respect to irrecoverable VAT for charities providing healthcare services. While the NHS is able to recover VAT on, for example, certain non-business supplies, charities are unable to do so. Of course, the NHS's ability to recover VAT on certain non-business supplies is written into Section 41 of the Value Added Tax Act 1994. Under current legislation, when services are transferred from the NHS to the charity sector, there is a VAT gap that needs to be filled either by charitable funds or by the local PCT.
	I shall give one small example, provided by Sue Ryder, one of they UK's largest specialist palliative care providers. One of Sue Ryder's hospices incurs £44,000 in VAT each year. If that hospice was run by the NHS, it would be able to recover 57 per cent of that amount under Section 41 of the VAT Act. That would allow the hospice to employ a nurse for around 44 weeks, or provide 1,500 bereavement sessions to families who had lost a loved one, or provide 2,500 hours of support from a carer. This amendment recognises that the Treasury has been engaged with the hospice sector to try to find a solution to the problem. I want to ensure that it remains on the Government's agenda, so the amendment asks them to present a report to Parliament on this critical issue.
	I am grateful to Sue Ryder Care for making me aware of this issue. As many noble Lords are aware, Sue Ryder provides specialist palliative and long-term care for people living with cancer, multiple sclerosis, Huntington's disease, Parkinson's disease, motor neurone disease, stroke, brain injury and other life-changing illnesses. It is one of the largest specialist palliative care providers in the UK, offering 4 million hours of care, over 100,000 days of long-term residential care, with the help of more than 8,000 volunteers. It provides vital services for people in their darkest hours of need. Who would argue that we should not do all we can to ensure that this continues? Yet these services are threatened. They face an additional burden at a time when the Government are asking organisations such as Sue Ryder to do more. It could be one of the many "any qualified providers" that are invited to take over services such as hospice care under the Bill.
	As far as I am aware, there are currently 36 NHS hospices, all of which are rightly exempt from VAT. I understand that the issue is complex. It concerns EU legislation as much as our own national fiscal policies. Moreover, the Government have previously expressed concern that addressing the unfairness for the charitable sector would subsequently create problems for the private sector. Nevertheless, I am not convinced by these arguments and find it untenable to believe that this House, with all its creativity, cannot address this problem. It is surely unreasonable to expect those who give charitable donations to organisations such as Sue Ryder to pay tax twice-their donations are from income that is already being taxed, yet the vital services which their donations go towards supporting are then taxed again for VAT.
	This issue is not limited to hospice services but affects many charitable organisations providing a range of health services. The situation is made all the more grave by the recent increase in VAT to 20 per cent. Estimates by the Charity Tax Group state that, prior to the rise in VAT, charities were paying more than £1 billion in irrecoverable VAT and that, after the rise, this figure has gone up by an extra £143 million. Sue Ryder informs me that approximately one-third of its income is from statutory services. What this means in effect is that, without its valuable contribution to care, the cost of providing it in the NHS would be two-thirds more.
	We should not expect the charitable sector and those individuals who give their hard-earned money to support it to subsidise care that everyone agrees is vital, yet we do. We not only ask the sector to continue to provide these services at such significant cost-savings but we add insult to injury by saying that it should do so without the tax benefits given to the NHS.
	I am aware from a discussion on this same issue in the other place that various solutions have been put to government to rectify the problem. One is the so-called "poppy" solution, whereby a matching grant for the VAT is given by way of return to the charitable organisation. This solution worked well for the Royal British Legion, and it should be possible to have something similar for hospice-care providers. It has also been proposed that relief enjoyed by local authorities and other public bodies under Section 33 of the VAT Act 1994 and certain healthcare provisions under Section 41 of the same Act could be used to assist hospices. Alternatively, similar exemptions to those in operation across the education sector, where academies are able to enjoy the same exemptions as those given to local authorities, could be used.
	To date, the Government have taken no action on any of the proposed solutions. Given the scope in the Health and Social Care Bill for additional services to be taken on by the sector, the need for action is even more urgent. The amendment seeks to strengthen the duty on the Secretary of State to promote equality in health service provision and would require the Secretary of State to report to Parliament on the way in which VAT has been treated with respect to charities providing health services. This would enable us, in a transparent way, to see clearly the impact of any inequity in this kind of provision and also the total impact on the sector.
	I am aware that more will be needed. There will almost certainly need to be two solutions to the problem-one pre and one post NHS reform. It is for this reason that the amendment seeks a report and not a solution. We want to ensure that we create a sustainable solution that applies when the clinical commissioning groups commission care. In order to do that, we need to have the information about how this affects voluntary sector service providers. I am sure noble Lords will want to discuss the merits and potential benefits of this approach and I look forward to their contributions. I strongly hope the Minister will see fit to accept the amendment and recognise that the unfair treatment of charities that are taking on health services from the NHS must be addressed as an urgent issue if the aims of the Bill are to be realised. I beg to move.

Lord Noon: My Lords, I wish to support the amendment moved by my noble friend Lord Patel of Bradford. I declare an interest as chair of the Noon Foundation, which has made significant donations to charitable organisations and others concerned with the care of those living with cancer and those in hospices or receiving palliative care in the community.
	My noble friend has outlined many of the key issues faced by the charitable sector with respect to VAT exemptions. I do not want to repeat these arguments, but let me add further information on the scale of the services that we are discussing. The combined contribution of these services amounts to more than 26 million hours of care every year. In excess of 2,000 adult in-patient beds are provided by the voluntary sector and more than £1 million is raised in charitable donations every day.
	Of course, these are voluntary sector services that rely on thousands of people who give up their time to ensure the work is done. In fact, the estimated value of the 100,000 volunteers is said to be more than £112 million each year. The value of this sector as a whole in providing hospices and palliative care is in the order of £3 worth of care for every £1 invested. This is an outstanding achievement that should make all of us very proud. It is also why we should be doing much more to protect the sector and ensure that it can operate and grow on a level playing field.
	I am a businessman so I know something about VAT and the need for equality in financial arrangements when different providers are in the same market. I am perhaps less anxious than some about the use of competition as a driving force in healthcare. I believe that competition can be harnessed for good and that there are many benefits to be realised by opening up the healthcare sector to this kind of discipline. However, competition must be fair and the current arrangements on VAT between health services and the charitable sector are certainly not fair.
	One of the charities that I have been most closely involved with, as a donor and a supporter, is Marie Curie Cancer Care. Marie Curie provides high-quality end-of-life nursing care throughout the UK and has more than 2,000 Marie Curie nurses, who care for half of all cancer patients who die at home. These nurses provide essential care for patients and their families at the most stressful time of their lives. I have met many of these nurses, and their dedication and passion is second to none. They not only provide essential practical support to people as they face the end of their lives but are an emotional support for the whole family.
	In addition to a range of community and home nursing services, Marie Curie is one of the largest providers of hospice care outside the NHS in the country. It runs nine specialist hospices which deal with all the patients' needs-physical, social and emotional-across in-patient and day-care services. These services are vital to those who use and need them but we should put them in this context: 65 per cent of people say that they would like the choice of being able to die in their own home, surrounded by family and friends, but the reality is that only 20 per cent manage to achieve this choice.
	It is clear that we need more of these provisions, and the Health and Social Care Bill will help to extend them. The new arrangements for commissioning mean that other organisations can provide more health services. This will also mean that there will be much more competition from lower-quality commercial organisations, but we must support them to be able to do this. Part of that support must be to ensure that there is a level playing field in respect of VAT. We should not expect charities to take up an extra burden in providing these vital services by expecting them to take on costs that do not currently apply to the NHS. The amendment provides a way of achieving this social goal by placing a clear duty on the Government through the Secretary of State's report to Parliament on the treatment of VAT provisions across the charitable sector. I hope the Minister agrees that it is an important move in the right direction and will support the amendment.

Baroness Finlay of Llandaff: My Lords, I declare all my interests in relation to hospice and palliative care services.
	The amendment is particularly important because of the any qualified provider provision which seeks to bring in more charitable sector providers, working with NHS commissioners, to provide essential services where the NHS is not able to plug the gap. That is why there was a debate in the other place in May this year on the effect of VAT on hospices. However, it goes much wider than simply hospices.
	The VAT gap means that the private sector can claim back VAT by passing on the cost to customers; the public sector pays VAT, which is then refunded by government; but the charitable sector can do neither-it fund raises. In the hospice world-I am grateful to Help the Hospices for the figures-an average hospital in the UK, supporting about 1,000 patients and spending £8 million on care, may receive about 30 per cent of its funding from the NHS but it will spend about £82,000 on irrecoverable VAT. So money has to be raised just to cover that VAT gap.
	As the hospital takes on more and more responsibilities, the problems become greater. As we try to get hospices to work together on joint ventures and share services with other providers and other charities, one hospice has to recharge services to another-one voluntary sector provider to another-including VAT, and that cannot be recovered. It also cannot recover any VAT on the repair and construction costs of charitable buildings. As there is increasing use of its buildings and it needs to upgrade to meet more modern quality requirements, VAT becomes a problem because, for the hospital to provide the quality service that we need, it has to outlay on capital expenditure.
	The other difficulty is that VAT is fairly complicated for charities and requires expertise to manage the VAT process for them, which of course also incurs a cost on them in terms of personnel, which again is irrecoverable.
	This is an extremely important amendment and the principle behind it has to be tackled if the fundamental idea of any qualified provider is to work in practice in the long term and provide stable, quality clinical services.

Baroness Pitkeathley: My Lords, charities have been campaigning about the VAT issue for many years. My charitable interests are declared in the Register of Members' Interests. Without doubt, the VAT issue is an unfair burden and a major inequality in the charitable sector. Why should it be of concern to us? Let us think of what charities are good at. In addition to the services outlined by noble Lords already, charities are good at spotting gaps and funding innovative solutions. They are good at bridging gaps, especially between health and social care. They are very good at seeing patients or service users in their particular situations and providing services which meet their needs and not some notional need determined by an assessor. Those things are going to be tremendously important in the new NHS going forward.
	Noble Lords should think of the contributions to care and health made by helplines, information provision, carer support groups and specialist nurses. They should think of the particularly significant service of incontinence supplies and advice-so vital to people with disabilities and to older people and their carers-provided extensively by charities. It is vital that charities are not only encouraged to continue to participate, but are also supported to do so-and not to be made subject to additional burdens such as those that noble Lords have outlined. The NHS and social care service cannot do without these services and, most importantly, patients, users and carers cannot do without them. Therefore, we must make it as easy as possible to provide for all qualified providers, including charities. I support the amendment.

Lord Turnberg: My Lords, I rise to lend my support this amendment. I speak here as a trustee of the Wolfson Foundation, which has a programme of support for hospices and care homes and over the years has given many millions of pounds, largely for capital projects. VAT is a constant source of unhappiness to the trustees, and, in fact, they have reached the conclusion that they will no longer pay VAT for capital projects. This means, of course, that the hospices and care homes themselves will have to find that money, which is unfortunate. Therefore, I hope that the Minister will take this amendment seriously.

Lord Warner: My Lords, I support the amendment and I do so from a background of having been the chairman of the National Council for Voluntary Organisations and a trustee of a number of organisations that have supplied services to the NHS and local government. This is indeed a very long-running sore; it is a sense of grievance. It often goes with another grievance-one which is not germane to this debate but which I might as well mention, because it explains why voluntary organisations are sometimes reluctant to provide some services for public authorities. That is a kind of meanness, almost, on the part of many public bodies about meeting the administrative costs-the management costs-of local authorities. If one takes the two together-a meanness about meeting management costs and being treated unfairly on VAT-this is a barrier to entry.
	I fully support the points made by the noble Baroness, Lady Finlay. As the Minister knows, I have probably made myself a little unpopular on these Benches through my support for the idea of competition on a level playing field. I have a later amendment which raises the issue of barriers to entry. This is a barrier to entry. It is stopping voluntary organisations participating fully on the basis of a level playing field as a qualified provider. Therefore, in terms of the Government's own philosophy in the area of competition, they would do well to listen to these arguments and remove this barrier to entry.

Baroness Armstrong of Hill Top: My Lords, I rise briefly to lend support to the amendment. I work with charities for the homeless and for children. If the Government's ambition is to enable the NHS to work with the patient on the full pathway-rather than work being done in little bits by different organisations-then making the playing field level for the voluntary sector is absolutely critical to developing those pathways. In my experience, the voluntary organisation is frequently the glue in making sure that the pathway for the patient works for the patient.
	I remind the Minister that when this works well there are often savings for the National Health Service. I have experienced that in homelessness, where we have been able to work with the PCT to get a community matron. That has reduced the number of expensive admissions to hospital and A&E for the most disadvantaged-the homeless. I have also seen that work well with, for example, children with disabilities and children who are very ill. They have been enabled to remain at home with the proper support instead of being frequently admitted to hospital.
	It is to the advantage of the NHS that we get this right. What will the Government do to bring forward in the Bill comfort and encouragement for the voluntary sector? After the pause, that sector has been left with a rather large amount of confusion.

Baroness Barker: My Lords, for over 25 years I have worked either in or as a consultant to voluntary organisations. Consequently, my eyes lit up at the sight of an amendment that said VAT and charities. In my time, I have sat with wet towels around my head trying to figure out this, one of the most complicated subjects. I have attended seminar after seminar with the Inland Revenue at which people with bigger brains than me have come away with their heads reeling from trying to understand the issue of VAT and charities. It is infinitely more complicated for charities than it is for the private or public sectors. That is not new. As various people have said, this issue has been running for some considerable time.
	I want to correct two impressions that might have been given inadvertently in the debate. First, there is the impression that there is a view in the charitable sector on this issue. There is not, because the issue effects different organisations disproportionately. While there may well be a consensus among hospices that it would be advantageous for them to make such a change, it may not be and indeed is not for other, smaller charities. That is the first thing.
	Secondly, we have this new generation of social enterprises. These organisations are not charities but businesses. They are intended to be big players in the provision of services. The noble Lord, Lord Patel, has been clever here in not asking for the Government to take a particular step. He simply asks for a report on a subject that will fascinate some of us quite deeply. Were the Government to take on board the point that the noble Lord makes, apart from looking at a whole range of different charities-not just hospices-would they also consider the effect on social enterprises? I do not think that it is possible to come up with a set of legal proposals that relate simply to health and social care. By definition, they would have to go across the whole of public services. I hope that the noble Lord, Lord Patel, would accept that an exercise of this kind should do that.
	Finally, be careful in the questions that you ask of HMRC. As someone who advised charities, I was always brought up never to ask a question of HMRC unless I was pretty confident that I would get back the answer that I wanted. This may be an answer that the hospices want but I would wish to be pretty clear that it worked for charities across the board. I simply finish by saying that if this subject were straightforward, it would have been sorted out a long time ago-but it is not and that is why it has not been.

The Lord Bishop of Chester: I am very grateful to the noble Baroness, Lady Barker, for what she just said about the complexity of the question. However, I would like to go back to what the noble Baroness, Lady Pitkeathley, said about what charities do well. Particularly important is their face-to-face concern with the whole needs of whole persons rather than the abstract application of principles. I would add two things that some charities offer that intersect with other bits of our social agenda at the moment. One is the passion of those volunteers who work particularly for local, small charities. A lot of energy is sapped by precisely the issue that we are discussing this afternoon. If we are concerned for what might be called in the most general way the big society, how you engage people in maximum participation at a local level in concerns and charities-particularly small ones, which are very close to the action-is extraordinarily important, it seems to me. Passion and localism are two aspects of this that must not be forgotten.

Lord Cormack: My Lords, I thought that the noble Lord, Lord Patel of Bradford, moved an absolutely model probing amendment, and the complexity of the issue was very well illustrated by the brief contribution of the noble Baroness, Lady Barker. I came not to take part in this debate but to listen, but I just want to say, as someone who represented a constituency in Parliament for 40 years, that I saw the enormously valuable work that so many charities did, particularly hospices and organisations that provide support, such as the Macmillan nurses and, as the noble Lord, Lord Noon, mentioned, the Marie Curie nurses, who do a very similar job.
	As we have this seminal opportunity to get it right, I hope that my noble friend the Minister, for whom I have enormous respect and regard, will be able to respond to this exemplary probing amendment in his customary exemplary way by indicating that the Government are indeed taking these matters exceptionally seriously. I hope that the Government are anxious to ensure, when this Bill emerges from Committee and goes to Report, that the Minister will have some remedies to meet the extremely important and pertinent points raised by the noble Lord, Lord Patel, when he moved this amendment and others who have supported him in this brief but, I think, important debate.

Lord Beecham: My Lords, like other noble Lords, I declare an interest in charitable organisations that are in the register. When it comes to the details of VAT and its complications, my expertise is roughly equivalent to that of Vince Cable. In the light of that, I took the very sensible advice of my noble friend Lady Wheeler and discussed matters with a charity here in London. It was quite an enlightening experience. I was told that the change in the world of voluntary organisations has made a significant difference to their position in relation to VAT. At one time, much of their income came from grants; now it is increasingly contracted. As contracting organisations, they become liable for the tax. For example, a new build for that particular organisation at one time would not have attracted VAT, but now it does; and as we have heard, there are other examples of that happening. Moreover, some of the services that it provides are exempt, as in education and social care, while others are not. As the noble Baroness, Lady Finlay, told us, smaller organisations in particular have to invest resources in getting the necessary advice to deal with their VAT problems. The organisation to which I spoke had an even more complicated position. It has a building, and because it is carrying out work that is both subject to VAT and not subject to VAT, it has effectively had to split the building into those parts that provide services that are exempt and others that are not; and there is a problem with mixed use in part of the building. It has to monitor and record everything scrupulously and file returns accordingly, so it is an extremely difficult position for such organisations.
	I congratulate my noble friends Lord Patel of Bradford and Lord Noon on bringing this amendment to the House, as it throws light on a significant anomaly affecting very many voluntary organisations-the very sector that all of us, especially I suppose the Government, in the light of their proclaimed belief in the big society, would wish very much to encourage. The amendment does not require a change in the law at this stage; it merely seeks a report. It is time that this long-running matter, which has endured for many years under Governments of both political persuasions, should be resolved on the basis of a report. It is of growing importance, as the noble Baroness, Lady Finlay, again reminded us, because of the position of any qualified provider, which would now be open to a wider range of organisations.
	At the moment, the anomaly exists in relation to the charitable sector and the National Health Service, but clearly there are other implications, including for the social enterprises to which the noble Baroness, Lady Barker, referred. In that context, it is interesting to consider the position of the voluntary sector compared with other organisations, some of which purport to be social enterprises. I cite the example of Circle, of which we heard a good deal last week and read about over the weekend. This organisation has now taken over the management of the Hinchingbrooke Hospital, which apparently had a pre-tax loss of £44 million in its last year. When it floated on the stock market, its prospectus said that growth would place,
	"a strain on its managerial, administrative, operational, financial, information technology and other resources and could affect its ability to provide a consistent level of service to its patients".
	I cannot imagine that any voluntary organisation, or most other social enterprises, would have come within a mile of obtaining a contract under those circumstances, and it seems strange that that contract should be given to an organisation of that kind while the voluntary sector is significantly handicapped by the current VAT regime.
	I hope very much, therefore, that the Government accept the amendment and undertake the review that it suggests, so that we might take matters forward and relieve them of a burden which reduces nobody's profits but does reduce the capacity of the sector to provide a better and wider-ranging service to the people whom it seeks to serve, and in whom we all have an interest.

Baroness Masham of Ilton: My Lords, how could one not accept this amendment?

Earl Howe: My Lords, I begin by saying that I completely understand the seriousness of the issues raised by the noble Lords, Lord Patel of Bradford and Lord Noon, and others noble Lords. The noble Lord, Lord Patel of Bradford, suggested that part of his purpose was to ensure that this issue remained on the government agenda. Let me assure him that the issue is very firmly on the Government's agenda, and I am pleased that we are having this debate today so that I can outline exactly what we are doing.
	Before I turn to address the amendment, I think it would be helpful if I briefly laid out the Government's view of the role of the voluntary sector in the NHS. We firmly believe that voluntary sector organisations have a strong and often crucial role to play, due to the experience, expertise and insights that they can offer to commissioners and the system more widely. I of course acknowledge and pay tribute to the valuable work performed by Sue Ryder and numerous other charities, including most especially hospices. We recognise that they can play a vital role in delivering innovative, high-quality user-focused services in their local communities, along with improved outcomes for patients and increased value for taxpayers. We also acknowledge, as Amendment 46 highlights, that taxation treatment is one potential barrier to voluntary sector organisations' entry into the provision of NHS services and to their increased involvement in those services. Access to capital is another. We are very keen to explore ways to overcome these challenges. The department is discussing this, as part of a wide range of issues, with voluntary sector providers of NHS-funded services.
	When I was preparing for this debate, I asked whether the Treasury was looking at these issues, and the answer is that it is. I understand that Treasury officials are already working with representatives from the voluntary sector to explore the value added tax treatment of charities supplying the NHS, taking into account the legal limitations and the potential complexities around possible solutions. We are keen that they should make speed over this. However, the introduction of an artificial one-year timetable, as this amendment proposes, would limit the scope for a full and thorough discussion and consideration of this issue. I cannot commit to that limitation. However, I emphasise that we are very keen to work at possible solutions as fast as we can. It is a complex issue. My noble friend Lady Barker pointed us towards some of those complexities.
	It is worth my repeating a general point here. The Government are committed to fair competition that delivers better outcomes and greater choice for patients and better value for the taxpayer. We want to see providers from all sectors delivering healthcare services. We have not the least wish to favour one type of provider over another. Indeed, as a result, and to ensure that the Secretary of State, Monitor and the Commissioning Board do not confer preferential treatment on any type or sector of provider, the Government have introduced amendments to Clauses 144, 59 and 20, inserting a new section, Section 130, into the National Health Service Act 2006.
	We know very well that the voluntary sector plays a strong role in bringing the voices and experience of patients, service users and carers to the work of improving services, often reaching individuals who are excluded or who cannot access mainstream services. The voluntary sector brings advocacy and information to support individuals to exercise choice and control over the services that they access. These are major prizes, and we wish to capitalise on them. Opening up services to greater choice, for example, through "any qualified provider"-as was pointed out by the noble Baroness, Lady Finlay-allows for greater involvement by social enterprises or voluntary sector organisations. To a great extent, this is already happening.
	Listening to noble Lords, I felt that there was a great deal of consensus around those points. There is a shared feeling across the House that charities have a key part to play in NHS provision, that the current VAT rules can act as a barrier and that this needs to be looked at very closely and urgently. I completely agree with that, and I would like to reassure the noble Lord, Lord Patel of Bradford, that we will ensure that this taxation issue continues to be considered urgently, as we develop work on a fairer playing field for delivering NHS services. In establishing Monitor's new functions, the department and Monitor will continue to consider these issues and the priorities to be addressed.
	The noble Baroness, Lady Armstrong of Hill Top, asked in particular what comfort there is in this Bill for the voluntary sector. She quite rightly mentioned the Future Forum in highlighting the work of the sector. The noble Baroness will be aware that the forum gave a very strong endorsement to the Bill's creation of a bespoke provider regulator, Monitor, in order to oversee a level playing field. Such a commitment to a fair market was and remains a comfort to the voluntary sector. Of course, we acknowledge that more needs to be done, and that includes the ongoing work at the Treasury.
	With those remarks, although I am sure that I have not completely satisfied the noble Lord, Lord Patel of Bradford, I hope that I have given noble Lords the sense that we are onside with this issue and shall be pursuing it with as much urgency as we can. I therefore hope that I have done enough to persuade the noble Lord to withdraw his amendment.

Lord Patel of Bradford: My Lords, I have listened carefully and with great interest to the many excellent contributions on this proposed amendment. I am grateful to the Minister for giving a very considered and what I believe to be a very sincere response by recognising the issues. Noble Lords have spoken eloquently about many of the issues: the huge numbers of services and people involved-it is absolutely the big society in action. Yet they also clearly talked about what goes to the heart of this Bill: the barriers that are there to stop the provision of equal services. My "unpopular" noble friend Lord Warner clearly outlined those barriers and I will not repeat them.
	We have heard from my noble friends about the importance of the voluntary sector. The Minister clearly repeated the importance of the role of the charitable and voluntary sectors, and the fact that they work with some of the most vulnerable people in our society. I completely agree with the noble Baroness, Lady Barker, about the complexity of the situation. She raised the important issue of social enterprises and the potential exemptions and disbenefits there as well.
	We are not asking to make a single-line solution to the problem; we are asking for clarity and transparency. This Government have clearly talked about transparency throughout, and it is so important for us to have that information. I listened to what the noble Earl said about them still discussing how the Treasury will go ahead and that they are in the process of taking urgent actions, but those urgent issues have been there for a long time. I suppose that I go back to the issue of my day job, when I am working with service users and local communities. When working with people with mental health problems and drug issues, nobody disagrees with me. Everybody says, "Yep-this is really important and urgent. We have got to look at it and we will. We will talk and we will make sure users are on the panel", but we are still talking about it 20 years on. We need a document or something that focuses the mind. That is why the amendment seeks to ask the Secretary of State to give us the data.
	I do not think that a year is problematic. I think it should be six months. Why do we not have these data? The whole premise of lots of the services we provide is that we need high-quality data to tell us what is missing and what is wrong. I am hoping that a report will be presented to give Members of the House an opportunity to reflect on that data and to look at what is going wrong, and where, because the big danger is that there will be a discussion between the charity sector and the Treasury, and that the Treasury will say, "This is what we can and cannot do-accept it". It is important that the House and others outside look at the data and the transparency within that and make an informed decision. I will not keep the Committee much longer. It is such an important issue and, as I genuinely think that we should have a report presented to Parliament by the Secretary of State, I therefore wish to test the opinion of the Committee.

Division on Amendment 46
	Contents 195; Not-Contents 183.
	Amendment 46 agreed.

Amendment 47A
	 Moved by Lord Kakkar
	47A: After Clause 5, insert the following new Clause-
	"Health Education England
	(1) The Secretary of State shall establish a body to be known as Health Education England, answerable to the Secretary of State and charged with the responsibility of ensuring and maintaining high standards of education and training of the NHS healthcare workforce.
	(2) In pursuit of that responsibilities, Health Education England shall have due regard to-
	(a) the responsibilities of the universities and the Royal Colleges and of other bodies involved with education and training;
	(b) the statutory responsibilities and authority of the regulatory bodies operating in the healthcare field; and
	(c) the necessity of ensuring that commissioning groups, foundation trusts, general medical practices and other qualified providers offer appropriate facilities for education, training and research."

Lord Kakkar: My Lords, I beg to move Amendment 47A, which stands also in the names of my noble friends Lord Walton of Detchant and Lord Patel, who, regrettably, cannot attend the Committee this afternoon.
	In moving this important amendment and speaking to Amendment 133 in this group, I wish to recognise the important statement made by the Minister on the first day in Committee on 25 October, when he made the case for an amendment to place a duty on the Secretary of State to exercise his function so as to secure an effective education and training system. This is an important and much welcomed recognition of the fact that education and training is absolutely critical to the delivery of healthcare.
	The Minister will recognise that, without an appropriate system of education and training, whether it be for a surgeon or a physiotherapist, a neurosurgeon or a nurse, a physician or a radiographer, or indeed a psychiatrist or an occupational therapist, patients will be put at risk. The important gains that the Bill proposes in terms of improving clinical outcomes will not be achieved and vital resources will be squandered.
	Education is at the heart of delivering effective healthcare. The professions, the public and indeed government have had previous experience of the introduction of changes in education and training with modernising medical careers that cause severe anxiety and disruption and have made all exceedingly sensitive to the importance of ensuring that any change in systems in the future provides the best opportunity for the patients who have to use health services in our country.
	It is well recognised that Her Majesty's Government wish to deal with education and training in a responsible and sensitive way, and it is broadly recognised that the changes proposed by the Bill raise anxieties about how education and training might be discharged in the future. In this regard, the commitment of the Government to seeking further clarification and the views of the NHS Future Forum is an important initiative. However, it would be impossible for the Bill to proceed unless there were absolute clarity with regard to education and training.
	The intention is that employers will play a much greater role in the future discharge of education and training functions, and there is no doubt that the education and training system must be sensitive to the needs of the service and, most of all, to the needs of patients. We must also ensure, however, that two vital issues are addressed. The first is the ongoing interaction and engagement with the academic sector, universities and educational expertise. It would not be right for employers alone to determine the nature and content of curricula associated with the training of the healthcare workforce. Secondly, notwithstanding that there will be a second Bill-most likely in the next Session of Parliament-to deal with health workforce education and training, it is critical that enough detail is associated with this Bill to ensure that we can continue with confidence in planning and organising the arrangements for the healthcare workforce to be appropriately trained and educated.
	With regard to interaction with those bodies, authorities and universities that have an expertise in the education of the healthcare workforce, will the Minister confirm that it is indeed the Government's intention that, in the proposal to establish Heath Education England-whether as a special health authority in the intervening period and, thereafter, ultimately as a statutory arm's-length body in a future Bill-there will be a requirement for Health Education England to engage fully with the academic sector? Will the development of curricula for the training of different disciplines in the healthcare workforce be set in partnership by service providers, employers and academic institutions working together to develop the curriculum? Will the working of local education and training boards be such that there is a clear relationship between them and Health Education England? Will the boards be composed of appropriate academic-health service partnerships to ensure that the valuable expertise in both the service and the academic sector can be brought into play to develop appropriate curricula and ensure that they are delivered to the highest standard; that those curricula are developed to meet both service needs and, most importantly, patient needs; and that, within the structure of local education and training boards, there are non-executive independent directors who ensure that any potential conflicts of interest are overcome?
	We have certainly been fortunate in having strong deaneries that have accumulated large volumes of expertise in and insight into the delivery of postgraduate medical education and training. It is important that these functions and this expertise are not lost in the system, and that postgraduate deans are potentially housed in universities in the future so that their important functions can continue to be delivered as part of the local education and training board structure.
	It is critical that there is an obligation on Health Education England to have an appropriate level of engagement and interaction with the royal colleges in medicine and other professional colleges. They are the regulatory bodies that play an important role in the supervision of training and the development of standards for practice in our country. Heath Education England should also be under an obligation to ensure that any qualified provider-NHS trusts, general medical practitioners and others-who ultimately has the responsibility and privilege of delivering NHS services has regard to providing appropriate education and training opportunities. This is vital, as the basis of education and training in our country has always been strong clinical exposure. If many of those clinical opportunities for training move to different service providers, the opportunities for education and training must not be lost. Amendment 133 deals with a further responsibility of the board and commissioning groups-to ensure that these interactions are properly addressed and that opportunities for training are not lost but well understood.
	I recognise that the Government are considering these matters through the work of the NHS Future Forum and in other consultations. The purpose of tabling these amendments is to probe the Government's view about education and training, and to determine whether there remains a strong commitment to academic service partnerships to drive forward education, training, innovation and research opportunities. These are all vital in ensuring that we have the highest-quality healthcare workforce for the future. They will also help us to understand better how Her Majesty's Government envisage the relationship between Health Education England and local education and training boards.
	Other amendments in this group deal with the important question of the future funding of education and training, and the importance of funding being ring-fenced and applied only for this purpose, rather than being put into potential jeopardy and used for other elements of the responsibility of the NHS Commissioning Board.

Lord Warner: My Lords, I rise to speak to Amendment 47B, which to some extent overlaps with Amendment 47A, which the noble Lord, Lord Kakkar, has moved so eloquently. I fully support the remarks that he made, particularly in relation to medical deaneries.
	I want to start from the position in which we find ourselves. This Bill contains a major reorganisation, which affects 1.4 million employees. As David Nicholson has said, the size of this reorganisation can be seen from space. I can remember making these rather trite speeches as a Minister about the NHS being the largest organisation alongside Indian Railways and the Red Army. Ministers before me made the same speeches just to emphasise the sheer scale of the NHS and the number of employees working in it. Therefore, it seems extraordinary that the Government could have considered for a long time reorganising this organisation in such a way without taking into account the education and training of probably the most labour-intensive and largest workforce in the country. It is not surprising that, in these circumstances, people in the NHS are very concerned about what is going to happen to education and training in this brave new world that the Government are taking us into.
	That is why some of us want to move amendments that go a good deal further than did the Government's amendment in this area, which seemed to me not unlike those Russian dolls-once you open one doll, another is inside and a smaller doll is inside that-in its endless reference back to other bits of legislation. We need something much clearer than that if we are to reassure the people working in the NHS that education and training are going to be safeguarded and looked after in a period of major disruption to the way we run our health service.
	Amendment 47B imposes a clear duty on the Secretary of State,
	"to provide or secure the provision of an effective system for the planning and delivery of education and training of a workforce of sufficient size ... to discharge his duties under this Act".
	That seems to me to be the focus that we should have in our discussions in this particular area. It tries to produce a clearer duty on the Secretary of State than the Government's Amendment 43, but goes further by requiring the establishment of a new body, Health Education England, to oversee, supervise and manage the current functions and national budget relating to multidisciplinary training.
	As we take the Bill through this House, it is not enough simply to say, "Oh dear, we are waiting on the Future Forum". I am sure that the Future Forum will have something good to say, but before this Bill leaves this House as an Act we need to produce much more certainty about how this service is to be continued and how the money is to be safeguarded. The size of the budget involved is considerable-somewhere in excess of £5 billion a year. Much of that money is looked after and spent by the rather maligned strategic health authorities, which will disappear in 2013 as I understand it. That money passes through them to the end-users of the money that deliver education and training. There is great uncertainty and concern about how national and regional planning of education and training, including the medical deaneries, will actually work, how they will be funded and how the current budget will be safeguarded.
	I recognise that employers need to play a full part in education and training, as the noble Lord, Lord Kakkar, has said, but I have seen the briefing by NHS Employers on this issue. That briefing makes pretty clear that there is huge uncertainty below the national level about how education and training will be managed when the strategic health authorities are abolished in 2013. People seem to be fumbling their way around, searching for a way forward when the SHAs go. We know that some activities cannot be left to local employers alone. A prime example of this is the specialist training that has to go on in securing placements for younger doctors coming through the early stages of their training and needing to have specialist postings to ensure that they can progress along the specialist route to fill the consultant posts of tomorrow.
	At the national level we need to achieve greater clarity on how the Secretary of State will discharge his responsibilities in relation to education and training. The Government seem to think that this can be left to legislation in the next Session but as far as I can see they can give no assurances, other than resting on good will and the Future Forum, to say clearly what this system would encompass, what it would look like and how it would work. The more sceptical among us have doubts about whether the Government will have the appetite for another Health and Social Care Bill in the next Session. If one was Prime Minister for a day, it would not be surprising to doubt whether one would entrust another Bill in this territory to the team that gave us this Bill. That thought must have occurred to the Prime Minister at some time in his busy life.
	In closing, I would like to say a few words about the third subsection in this amendment. This is in response to the concerns that have been expressed that many current functions and their budgets will be passed to the national Commissioning Board almost by default, and at the very time when the crisis on meeting the Nicholson challenge of saving £20 billion in four years will be moving to crunch time. I suppose there is a kind of poetic justice that David Nicholson should be asked to consider his own challenge and deal with it as chief executive of the national Commissioning Board, but people are concerned that temptation should not be put in his way in the form of the £5 billion or so of the budget for education and training work of the NHS. To help him resist that temptation, should it arise, this amendment includes a formula for preserving the education and training budget. It may not be the perfect formula-I am sure that noble Lords across the House would be willing to discuss a better one-but some kind of formula and ring-fencing which protect the budget for education and training is a sine qua non if we are to carry with us staff up and down the country working in the NHS whom we expect to continue to deliver a highly effective NHS at a time of great organisational change.
	Of course, the Minister may be able to reassure us all and give us some guarantees, and I look forward to hearing them. These need to be guarantees about how the amount currently spent on education and training will be safeguarded. We will also want to know: what is to happen to the money when the SHAs are abolished? What division of responsibility between Health Education England and employers are the Government planning? Do the Government envisage a role in this sphere for the national Commissioning Board? I hope the Minister will not simply say that the Government are waiting for the Future Forum to report.

Lord Turnberg: My Lords, my name is attached to Amendment 47B, so ably introduced by my noble friend Lord Warner. I simply wish to emphasise some of the points that he has raised and some of those raised by the noble Lord, Lord Kakkar. The amendment is an attempt to fill a conspicuous gap in the Bill in relation to education and training-namely, to introduce at this stage the idea that we have a Health Education England. I recognise of course that we are waiting for further information from the Future Forum and that we should expect further legislation on this in due course, but this is a subject on which we cannot afford to wait. We need something in this Bill, if only to try to settle some of the many uncertainties that are so disabling for many out there. We cannot wait for a second Bill at some uncertain and probably distant time.
	The White Paper Liberating the NHS: Developing the Healthcare Workforce is frankly disturbing in some of its recommendations. Putting responsibility for education and training at the local level entirely in the hands of provider networks-so-called local skills networks-is to my mind, and that of many I have spoken to, both dangerous and potentially damaging. Of course we need, and should have, local input in planning for local workforce needs. However, the standards of education and the level of skills and knowledge that patients deserve have to be set on a national scale. It is not helpful to have a healthcare worker trained solely for local needs who is unable to transfer to another part of the country without going through another local training scheme. Training must be transferable. For that we need national curricula, assessments and levels of achievement, so that when a new healthcare worker joins an organisation, the organisation can rely on that training.
	At the moment, for medicine at least, the GMC sets the overall standard and the royal colleges and their specialist advisory committees provide all the curricula and set the exams, assessments and qualifications so that employers and patients can rely on the fact that a newly appointed cardiologist or surgeon, for example, has reached a recognised and approved standard on a national scale. However, most of the medical, nursing and other training takes place at the coal face: in the wards or in general practice by trainers who are themselves practitioners. Here, out and about, the postgraduate deans play the pivotal role because they oversee the whole process of training and planning of the workforce for their part of the country. The deans are the glue that makes it all happen. They control, of course, the budgets for the salaries of all the medical trainees. At the moment, they are employed by the strategic health authorities. When those authorities disappear, the current proposal is for them to be taken over by local provider skills networks. I have already suggested that it would be unfortunate if these bodies were purely NHS providers with little input from those with experience of what education and training entails. Providers may know something about what they want out of it at the end, but they are not set up to oversee and provide the education by themselves.
	There are two things that must happen if we are to have a reliable system. First, Health Education England must be set up now, as this amendment suggests. This organisation should become a focus for the postgraduate deans and should probably be their employer. Secondly, we must make more use of the expertise in education that lies in the universities across the country. While universities are engaged in nurse education and that of some other healthcare workers, we must be one of the few countries in the world where universities play little or no formal role in postgraduate medical education. Of course, most clinical professors and their staff are engaged in teaching postgraduates, but the universities have no formal roles. It makes quite a bit of sense, therefore, to consider having the universities play a much bigger role in the local skills networks with the NHS providers. The postgraduate deans might indeed be employed by the universities if they are not to go into Health Education England, although I am not suggesting that their budgets go across to the universities-that may be a step too far.
	Perhaps I may ask the Minister whether it would be possible for the deans to be seconded to the local university. It might well be a valuable outcome if the deans could then work closely with local NHS/academic partnerships rather than with NHS providers alone. The example of the academic/health service partnerships set up as collaborations between the NHS and universities to encourage research and the transfer of innovation into practice, as initiated at UCL, might be worth following, and I hope that it might find favour with the Minister. A new partnership built on this kind of model, with deans, providers and universities, and advice from the royal colleges and oversight from Health Education England, would, I believe, find a lot of favour. It would not be providers alone, and it would not be universities alone-where we have seen some of the difficulties associated with nurse education-but a balanced combination of the two. I hope that we can see something emerge along those lines. If that is seen to be the general direction of travel now, even if the detail comes later when we have seen the Future Forum's report, it will settle many of the anxieties that exist.
	I understand that there is an intention to set up an interim Health Education England some time next year, but unless it is given the budget for education, some £5 billion a year, and if the money is instead diffused into local skills networks in the meanwhile, I fear that it will be lost for ever. That is why we should have a clear statement in the Bill now about Health Education England and its funding.
	The other part of the amendment refers to the need to ensure that the funding for education and training is not eroded in the changeover, and I hope that the Minister can give us some comfort there, too.
	I know that there is much more work to be done by the Government, but we should not leave this until some uncertain future. We must have something a little more concrete in this Bill, and I hope that the Minister will be able to help us.

Baroness Emerton: My Lords, I have put my name to Amendment 47B. At Second Reading, I referred to why I thought it important that education and training be mentioned in the Bill, even though it was understood that work was already under way. Noble Lords who have spoken have underlined the importance of education and training being mentioned in statute now.
	The Health and Social Care Bill proposes a comprehensive health service reliant on an effective workforce that is capable and competent to deliver a service that demonstrates improved patient outcomes. For this to happen, there needs to be an effective partnership between the NHS and universities. The introduction of local commissioning of services will also require local commissioning for education and training places for the agreed workforce plan at both local and national level. There must be multi-professional involvement if professional silos are to be avoided, both in relation to funding and the structures and governance arrangements that underpin the workforce. For too long, silos have been the problem in the funding arrangements for education, training and research.
	Developments around the establishment of the Health Education England are now being considered, but, as has already been said, progress is slow and is causing anxiety out in the field. The intent to move to an integrated health and social care service calls for these partnership arrangements to be made. There is a need to ensure the right balance of responsibility and accountability between Health Education England and the provider-led networks-employers/professions, the education sector and the whole workforce, plus patient and public representatives, working together. It is vital that this is a proper partnership and representation on the boards of local education and training boards, which can ensure effective multi-professional workforce planning. Representation of universities, medical schools and postgraduate deaneries, in relation to both non-medical and medical education, on the board of the local education training boards will ensure effective co-production of the healthcare workforce.
	Universities should not be considered simply providers of education programmes but also co-producers of the workforce through this wider role of research, innovation, releasing social capital, and the globalisation of healthcare, which is integral to the development of advanced clinical care, service redesign and workforce planning. Universities should work in co-operation with the NHS to ensure the delivery of high- quality education and training and then be held to account by Health Education England. Ensuring that universities are a central part of the local education will facilitate effective partnerships, improved quality outcomes and a multi-professional approach.
	The intent to move to this is very important and the establishment of budgets, which has already been mentioned, is also crucial. As already stated, silos should be avoided so that an integrated approach can be established to the education and training of the workforce. The challenge for the new education system will be whether it can truly ensure the co-product of a workforce that can deliver the new way that care can be delivered-one that will provide holistic care, especially adapting to the demographic changes, demanding more care in the community for the elderly, frail, vulnerable and for end-of-life care. Budgets will need to reflect the most cost-effective provision of care to enable hospital expenditure to be reduced.
	Nursing, midwifery and other allied healthcare professions are committed to evidence-based practice and would warmly welcome the multi-professional involvement in education and training programmes as well as the benefit gained from multi-professional buildings and shared facilities. Not only would this be of benefit for the learning environments but it could be cost-effective in the use of expensive educational facilities, tutorial staffing and equipment. Could the Minister clarify some of these issues in his summing up?

Baroness Finlay of Llandaff: My Lords, I have an amendment in this grouping. It addresses the duty that I would like to see on clinical commissioning groups to promote education and training of the current and future NHS workforce. The reason for putting the future in is because of the undergraduates who are studying to become healthcare professionals. This is important because we know that primary care placements at undergraduate level have a significant influence on career choices and therefore on career progression. The quality of training and the quality of care given by the tutor who is their tutor in primary care is influenced by having undergraduates with them. That applies across all the disciplines that work in the community.
	The other point is that general practitioners will need training in commissioning responsibilities in the future. Therefore, if we are to attract the brightest and best of our undergraduate clinical workforce to work in the community and eventually contribute in clinical commissioning groups, they need to have excellent exposure at an undergraduate level.
	I also support the other amendments in the group so eloquently introduced by my noble friend Lord Kakkar. I strongly support the comments made by all the other noble Lords who have spoken. We need to have this duty at every level-at Secretary of State level, at commissioning board level and, as I have suggested, at clinical commissioning group level. The one area that we have not addressed and that is not in the amendments is the way that Monitor grants licenses. We might need to come on to that at a later stage when we discuss Monitor.
	There is a particular need for planning medical education and training and having it planned nationally. It takes 15 years, on average, from start to finish to develop a specialist in highly technical, very complicated areas of medicine. There are about 32 small specialities, and in-depth local intelligence and intelligence within that speciality are needed to know both the numbers that are needed in the future and to horizon scan and look at the type of training that will need to be delivered and whether things will change. A simple example is in surgery, to which reference has already been made, where keyhole surgery came about. My discipline, the development of palliative medicine as a distinct speciality, has completely altered the face of some of the care in both hospitals and the community, and it has a significant workforce which is still developing.
	There is also a need for reliable information on education and training so that the Centre for Workforce Intelligence can work with the proposed Health Education England to ensure that there is good information and opinion decisions. Quality management of education and training in medicine is currently undertaken by the deaneries, by and large, and that should be built on. They provide independent quality assurance. If the dean is the responsible officer and has a ring-fenced budget and a financial lever, they can withhold funding for posts and have been shown in many parts of the UK to rapidly drive up quality where there have been concerns about the training environment into which trainees were going. It is not difficult to expand that system to take on postgraduate deanery structures for the other disciplines as well.
	I strongly endorse the need for the allied healthcare professionals and nursing to come under the new structure as well. There is a need for inter-professional working and learning. Inter-professional learning and integrated delivery of services with integrated learning will drive up the quality of care and ensure the development of good clinical leadership so that we bring the level of the best into the delivery and content of education and training.
	The commissioning groups, in particular, must ensure that there are appropriate facilities for education and training. The quality of the commissioning they do at a local level, with both NHS and other providers, will ensure that undergraduate and postgraduate students can be placed in and learn from a wide range of services. We will then have a workforce fit for the future.
	Health Education England, when established, can audit the local education and training boards and maintain a national perspective. There is worrying information about the way things are going. I have spoken to the Medical Schools Council, which recently surveyed medical school involvement in the development of the emerging local education and training boards. It indicates a variable extent to which higher educational institutions are involved in planning and suggests that the structures will vary widely. In some areas, such as the north-west and the east Midlands, medical schools and higher educational institutes appear to be actively excluded from the developing local education and training boards. This is extremely worrying because in service transformation there needs to be quality control and academic rigour. Medical schools are required by the General Medical Council to act as quality managers of clinical placements but, by excluding those which are providing education from the local education and training boards, we risk having a serious disconnect in the way that services develop and are delivered, and in the way that our workforce is trained.

Lord Ribeiro: I have listened to the debate with considerable interest, particularly as it brings to our attention the whole concept of Health Education England. I think Health Education England is a work in progress, and the reason I say that is that, as a result of the MMC/MTAS debacle that took place in 2006-07, one of the major recommendations of the inquiry that followed by Sir John Tooke was that a new body should be set up called Medical Education England. That recommendation was accepted by the Government at the time, and by the Opposition. It started work under the chairmanship of Dr Patricia Hamilton, who has come to this House to give her views on the development of education and training.
	The reason I mention that is that Medical Education England was designed to deal with medicine. Yet, as the noble Baroness, Lady Emerton, has said, more than 50 per cent of the multiprofessional education budget actually goes on nurses and other non-medical members. Therefore, it is totally inappropriate to be moving on to a Medical Education England model when clearly we have to encompass all the other health providers, and hence we have Health Education England. I understand the desire of the noble Lord, Lord Warner, to get on with this but, to get this to work, it needs to be thought through very carefully. One of the reasons-certainly from the medical point of view-is that, among the questions we asked in 2006 was, "What is the end point of training? What are we training these doctors for?". One has always assumed that most medical treatments will occur within the hospital sector but we know, because of the ageing population, that more and more is being done in general practice and in the community. We therefore need to think very carefully about how we train doctors for the future and where they are going to work.
	It is important, therefore, that we give time for the development of the workforce as well as the training and the education of the workforce. The noble Baroness, Lady Finlay of Llandaff, referred to the Centre for Workforce Intelligence, which is very important, but that is a new agency. I was in America last year, when a representative from it came to brief the American College of Surgeons Health Policy Research Institute on how it was trying to work out where doctors should go within the UK with respect to geography as well as specialty. They were taking advice from the Americans as to how they were trying to map and plan their health workforce.
	I think this is work in progress. I welcome that this is a probing amendment, but I do not feel that at present we are in a position to roll out Health Education England without having heard the full report from the Future Forum.

Lord Owen: My Lords, I reiterate some of the comments that have already been made by many noble Lords on the sense of urgency about this issue. Above all, I feel rather like the man in the Bateman cartoon who mentions the words "party politics" in the Health and Social Care Bill in the House of Lords. There is here a very deep question. It is frankly inconceivable that there will be legislation in the next Session; I would think it would be almost inconceivable that there would be legislation on this before the next election, which is currently scheduled for 2015. Politicians simply do not usually go in for a repeat hiding, and this Bill has already had one hell of a political controversy. If we have legislation, it may be all on medical education, but it opens up a whole realm of party politics, which I just do not see being done.
	Therefore, I want to make a practical suggestion to the Minister. There is a way through this if there could be bipartisan agreement. One only has to think of a situation in which there is no legislation until 2016 to realise that we are facing a real chasm in medical education and continuity. As I understand the legislation, the Secretary of State is empowered to create special health authorities. Whether he does that or removes the ones that are necessary, that power is there. If not, he could easily take it in the Bill.
	There is so much cross-party agreement that doing something about health education is pretty urgent. I would have thought that it would be perfectly possible to meet most of the demands. The noble Lord, Lord Ribeiro, is completely right. We are not in a position to legislate now on anything other than a structure. That structure might be a temporary special health authority. It is not worth prejudging the question but, if it was a special health authority, it would need some form of regulation passed. As long as an agreement could be made-first on the clause that would be in the Bill, along the lines more of Amendment 47B than 47A; and, secondly, with the main substantive regulations for the special health authority done through an affirmative resolution-then it would be perfectly possible for us to move on the creation of this training authority, which has to embrace all the health professions and be pretty wide-ranging, some time at the end of 2012 or early 2013. That would meet the wishes of most people in the National Health Service.
	It is really not enough to rest on the fact that there will be a Bill in the next Session of Parliament. I have already tried to convince my own college, the Royal College of Physicians, that it is highly unlikely that this will be fulfilled. As practical politicians, we should ask the Minister to take this away with a measure of real good will to see if there is some way through this issue which does not prejudice the long-term future but allows us to fill a very serious gap.

The Archbishop of York: My Lords, I too support the amendment of the noble Lord, Lord Warner. Proposed new subsection (2) simply says that:
	"In discharging this duty, the Secretary of State must establish a body known as".
	It does not tell us the rest of the details. It puts a duty on him or her to establish a body responsible for,
	"the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries".
	How will it deliver that? What is going to be its content? That is for the Secretary of State in the future. But we fail in our responsibility if we miss the opportunity right now in the Bill to flag that up as part of the duty of the Secretary of State.
	Noble Lords may remember from Second Reading that I spoke against supporting the Motion of the noble Lords, Lord Owen and Lord Hennessey, because I wanted to ensure that the constitutional duty of the Secretary of State is to promote a comprehensive health service and improve the quality of that service. I told the House that I have recently spent time in three different NHS hospitals: University College, London; St Thomas's Hospital; and York Hospital. These are teaching hospitals. I was more than content that whenever the doctors saw me they came with a large range of nurses, doctors and those in training of all kinds. I became a guinea pig. I did not mind because I knew that I was in a training hospital. How are we to ensure that our National Health Service has that responsibility of making sure they are training hospitals? We must not assume that our NHS delivery of clinical care is almost like the assembly line of a motor car where you fix it and it goes out okay. It is not that kind of thing. What distinguishes most of the best clinical practice is the fact that our National Health Service has these training hospitals. I would be unhappy to know that the Secretary of State had not established a body, known as Health Education England, with responsibility,
	"for the oversight, supervision and management of all current functions".
	Where will those lie when the Bill has been passed?
	Last time, when we debated other amendments, there was a worry about the diagram of the proposed structure of NHS reforms in the Bill. I drew one up for myself. Listen: the Secretary of State is on top, then there are other bodies-Public Health England, HealthWatch England, the Care Quality Commission, Monitor, NICE, clinical senates and networks, the NHS Commissioning Board, local HealthWatches, health and well-being boards, the community voluntary sector, local government social and public health, and multiple clinical commissioning groups. Where is education in all this? When the Minister replies, will he tell us where he thinks education is going to lie? If it does not lie within this Bill, with its already very complicated structure, the next time I am being treated in the NHS I will be crying, "Where are those learning as I am being treated?".

Lord Mawhinney: My Lords, I do not intend to detain your Lordships very long. However, I very much hope that my noble friend the Minister will consider, as I do, that these amendments and this debate are premature. I do not think that we should be focusing on the substance of these debates other than to point out to my noble friend, as was pointed out when we did this a few sittings ago, that there is a broad sense of the importance of putting on the face of this Bill the responsibility of the Secretary of State for education and training. In that sense I agree with the most right noble Prelate-with the Archbishop of York.

Noble Lords: Primate!

The Archbishop of York: Call me whatever you like.

Lord Mawhinney: I am a just a simple Belfast boy. Archbishop of York seems pretty good to me; most of the clergy I know can only fantasise.
	The timing of this debate is important in that it reinforces the message that my noble friend got the last time this was debated in this Chamber. I hope that he will tell those who tabled the amendments that they are premature. If he does, he will need to tell them that he will take away the contents of this debate and the previous one and bring back, in whatever way the Government think is appropriate, a means to attach the principle of education and training to this Bill. He knows that I hope that he will do that, but I hope that he is encouraged that I share the views expressed that this is not yet the time.
	The noble Lord, Lord Owen, has addressed particularly well the element of perplexity and perhaps confusion in the NHS about the Government's intention. My noble friend and his colleagues keep going on about the Future Forum. I am sure that it is doing a fine job, and no word of criticism about it will cross my lips-except to say, as a simple Belfast boy, that in a democracy it seems to me that the role of this House is to try to persuade Ministers; it is not its role to try to persuade those who are going to try to persuade Ministers. The Future Forum may have an important role, but I would like us to discharge our role quite clearly. The noble Lord, Lord Owen, has the experience of having served in Cabinet, and I have been extremely fortunate and blessed to have had a similar experience. If my noble friend or the Secretary of State can go to the Dispatch Box and say, "I undertake that there will be legislation", and specify the Session, we will all believe him. However, if that is not possible, it adds to the importance of bringing forward at least the principle to get this issue into this Bill.
	Those of us who are in favour of education and training but want to support the Government are not entirely clear whether we should be tempted by Amendments 47A, 47B or 133, and I have to say to the noble Baroness, Lady Finlay, that I am not tempted by her Amendment 199A. But at some point this House has to make a decision, so I hope that my noble friend will stand up, look the noble Lords who tabled these amendments in the eye and say, "Thank you, it's been very helpful and I've heard what you've said. I'll take it away and I'll bring something back on Report, which I hope will satisfy the whole House". In the mean time, I hope that noble Lords will not press their amendments.

Baroness Finlay of Llandaff: I hope that the noble Lord, Lord Mawhinney, will be tempted by this comment. If commissioning groups do not have a duty towards education and training, there is a real danger that they will commission services that are equal in quality but undertake no education and training and are therefore of a lower price as they do not incur the expenditure of having to have facilities, and so on, to provide education and training as well. In that case, we will deny the developing workforce expertise of quality placements in many parts of Britain as local commissioning will not take account of it.

Baroness Thornton: My Lords, at the risk of stating the obvious, the massive reorganisation of the NHS proposed in the Bill, combined with the need to make £20 billion of efficiency savings, without doubt, and with common agreement across many of the professions, threatens the quality and delivery of medical training, post-graduate training and workforce planning. That is why noble Lords have been exercised about this matter from the outset.
	The concern is that responsibility for medical training will be given to healthcare providers who, as I understand it, have a history of allowing service and research to dominate the agenda at the expense of education. That brings with it risks of its own. Many trusts, as other noble Lords have said, have persistently failed to support education supervisors by recognising this activity in job plans and increasingly failed to support their staff in fulfilling important national roles related to standards setting and training. I think that most noble Lords who have spoken would agree that there is an insufficient mention of the safeguards that need to be put in place to protect the quality of medical training.
	The noble Lord, Lord Kakkar, and my noble friend Lord Turnberg mentioned their concern about post-graduate deaneries. Indeed, that was a major stream of work for the Future Forum. I would like to say to the noble Lord, Lord Mawhinney, that as he made his remarks about the Future Forum I wrote in my notes that I do not understand why the Department of Health seems to have franchised that particular piece of policy-making out to the Future Forum. I think that the Future Forum was right in what it said about the dangers and risks involved in abolishing the strategic health authorities and its recommendation that it was mandatory and critical that alternative arrangements should be made.
	We know that post-graduate deaneries are currently pivotal in quality managing the delivery of medical training in trusts, but the planned replacements, being answerable to and funded by healthcare provider units, may lack the impartiality required to drive the quality agenda at a time when it is most needed because of the fiscal pressures and the associated threat to education quality. We all agree that effective management of the complexities of post-graduate medical training require professional leadership skills and experience, which take many years to develop. The noble Baroness, Lady Finlay, underlined that point in her remarks. My noble friend Lord Warner put his finger immediately on the crucial aspect-how will the money be safeguarded and how will we make sure that the funding that is necessary is in the right place, is accountable in the right place, and cannot be directed into places that we would not wish it to be? How will the Government make sure that that is what happens?
	I was very struck by the briefing on this matter by the Royal College of Nursing. The noble Baroness, Lady Emerton, referred to this. The Royal College of Nursing expressed its concern that Medical Education England would dominate the new organisation, HEE. I think we would all agree with the RCN that:
	"It is essential that nurse educators are treated as equals and the membership of HEE is representative and not led by the medical deaneries".
	The Royal College of Nursing also believes that there is an essential role for national planning in the delivery of these important functions. I think that there are great risks in the decentralisation of education and training in terms of quality, standards and safeguards. It is unclear how the skill networks or the LETBs will be held accountable for performance issues. It is not clear what authority Health Education England will have to enforce performance issues or how its overseeing of the skills network will take place.
	There are some key questions for the Minister to address. The crucial one, which was mentioned by the noble Lord, Lord Owen, who used the expression "chasm in continuity", is how long we will have to wait for legislation. We cannot be sure that the primary legislation that will be required in this area is going to come down the track in the next year. The Minister needs to recognise that it is too risky to leave this to chance and we have to put the appropriate duties and powers in the Bill to ensure the continuity that the noble Lord, Lord Owen, mentioned. On these Benches, we are very happy to discuss how to resolve that particular issue and how to ensure that medical education is safeguarded.
	This is an important group of amendments. I am slightly worried by the statement of the noble Lord, Lord Ribeiro, that this is work in progress. The problem is that there is too much work in progress and there will be too much work in progress for the next few years. This is an area where we cannot take chances. We know from previous reorganisations, for which my Administration were responsible, that we have to be absolutely sure that we are safeguarding the education and training of future generations of workers in the National Health Service.
	The most reverend Primate said that continuity and certainty are vital. I agree with him. Certainty in this area is vital. I look forward to hearing the Minister's views, but I suspect that we have not heard the last of this subject.

Earl Howe: My Lords, the Government are clear that the education, training and continuing development of the healthcare workforce are fundamental in supporting the delivery of excellent healthcare services across the NHS. I am very pleased that so many noble Lords here today share that view. It is certainly the Government's view. I very much welcome what have been excellent comments on this subject.
	Amendment 47A, tabled by the noble Lord, Lord Kakkar, seeks to insert a new clause placing a duty on the Secretary of State to establish a body called Health Education England. Similarly, Amendment 47B, tabled by the noble Lord, Lord Warner, seeks to place a duty on the Secretary of State to "provide or secure" an education and training system and to establish Health Education England to take responsibility for these education and training functions. Amendment 47B also specifies that the budget for education and training should be calculated on the basis of total health service expenditure and,
	"should be no less than the level of expenditure on education and training at the time of Royal Assent".
	The Government recognise the importance of having an effective education and training system for the healthcare workforce. The NHS invests approximately £4.9 billion centrally in the education and training of health professionals. It is vital that there is a robust system in place to manage this investment wisely, with clear lines of accountability to Parliament. I would point out to the most reverend Primate that that is exactly why we tabled Amendment 43 which, as the Committee will recall, we debated in our first session. The Committee has already approved that amendment, which is now in the Bill and which says that there is a duty on the Secretary of State to exercise his,
	"functions ... so as to secure ... an effective",
	education and training system. It is perhaps worth my flagging up that that amendment has received a positive response from the British Medical Association, which, in the current circumstances, is a rather remarkable fact. I reiterate that it is designed to ensure that the healthcare workforce has the right skills, behaviours and training to deliver a world-class health service. But we want to put flesh on the bones here. We recognise the need to do that and I therefore undertake that we will publish detailed proposals for the education and training system ahead of the Bill's Report stage where we will describe how this duty will be enacted in practice. However, there are parts of our plans that I can set out now.
	It is vital that we ensure a carefully managed transition into the new system and protect staff and students currently undertaking training. We are taking a number of actions in developing the new system to achieve this that I would like to highlight. The Future Forum recommended that the establishment of Health Education England should be expedited to provide leadership and stability in the system. We agree and it is heartening to see that many noble Lords support this course of action. We have appointed a senior responsible officer to drive this forward and inject pace into the design and development of Health Education England.
	To respond to the noble Lord, Lord Owen, while I do not share in any way his analysis of the future prospects of the next health Bill, he was right on one matter: we plan to establish Health Education England as a Special Health Authority in 2012. This will enable it to take on some of its functions from October 2012 and be ready to be fully operational from April 2013. There is not and there will not be the chasm that the noble Lord referred to. Noble Lords will have a chance to scrutinise the establishment order and regulations to set up Health Education England as a Special Health Authority when they are laid before Parliament in early summer 2012. Lest there is any doubt on the matter, I reassure the Committee that it is our intention that Health Education England should form excellent partnerships with a full range of bodies involved in the planning, commissioning, provision and quality assurance of education and training.
	However, I can say in particular to the noble Lords, Lord Warner and Lord Kakkar, that Health Education England will provide national leadership for education and training, overseeing workforce planning and the commissioning and delivery of education and training across the system. We have been clear about its accountability to the Secretary of State to ensure that, at national level, there are sufficient health professionals with the right skills, education and training to meet future healthcare needs. Providers of NHS services will be expected to meet the obligations set out in the NHS constitution, including the right of recipients of NHS healthcare to be treated with a professional standard of care by appropriately qualified and experience staff. Health Education England will hold responsibility for the management of the NHS multi-professional education and training budget, or MPET. To ensure that this budget is sufficient to support the development of the future NHS workforce, equipped with the right skills, our intention is to base the size of this budget on the needs of the service, supported by robust analysis of local workforce and education and training plans.
	The question of postgraduate deaneries was raised in particular by the noble Lord, Lord Turnberg. The SHAs will continue to be accountable for postgraduate deaneries until 31 March 2013. Securing continuity for the work of the deaneries will be a key part of a safe transition. It is expected that deans and many of their staff will continue to take forward the work of deaneries with an emphasis on a new, multi-professional approach in the new system architecture.
	To pick up one point made by the noble Lords, Lord Kakkar and Lord Turnberg, we also want to see stronger partnership working between postgraduate deaneries and universities. Further work is under way on the detail of these arrangements, with the right accountabilities for the quality of education and training lying with Health Education England and the professional regulators.
	I was asked by the noble Lord, Lord Kakkar, about ring-fenced funding. As he knows, the MPET budget currently funds the education and training of the healthcare workforce and it is the responsibility of SHAs to invest the budget appropriately. We have proposed transparent systems to ensure that organisations receiving MPET funding under the future arrangements are held to account for using it for the education and training of the workforce.
	The noble Lord also asked whether there will be a requirement to engage fully with academics. I partly covered that point but I emphasise that the new system presents a golden opportunity to build stronger links between the NHS and the academic health sector and to strengthen the educational foundation for research and innovation. Health Education England will ensure that research capability and capacity is maintained and it will forge strong partnerships with academia. Health Education England will work with the royal colleges, the Academy of Medical Sciences, regulators, universities and service providers to ensure that the needs of healthcare delivery are reflected in developing curricula in the context of the statutory responsibility of regulators.
	The noble Lord, Lord Turnberg, asked me about standards. I reassure him that standard-setting will be the role of Health Education England at a national level, and this is in addition to the important role that the professional regulators play in this area.
	However, despite the progress that we have made, a lot more work has to be done to get these important arrangements right. In my view, that is why it is important that we do not try to amend the Bill in a way that later turns out not to be appropriate. The Future Forum is now leading a second phase of engagement on education and training, focusing particularly on the need for greater flexibility in training, variation in standards and quality, and the need for stronger partnership working between education, academia and service providers. I take this opportunity to mention that tomorrow I am hosting a seminar with Professor Steve Field, chair of the forum, and I welcome your Lordships' involvement.
	I appreciate that the service is waiting for detailed plans for the education and training system to be finalised and published, and I have two promises that I can make on this. The first is the one to which I have already alluded. Once the Future Forum has concluded its work, and prior to Report, the Government will publish more detail on the changes to the workforce planning, education and training system. That, incidentally, will include more detail on postgraduate deaneries. Secondly, it is likely that primary legislation will be required to support the continuing development of the education and training system, including establishing Health Education England as a non-departmental public body, but we think it is important to spend time to make sure that these arrangements are correct rather than legislate at this stage. However, I can tell the Committee that we intend to publish draft clauses on education and training for pre-legislative scrutiny in the second Session in the same way as on research. This approach will enable us to ensure that the legislation is fit for purpose and that it allows additional opportunities for parliamentary scrutiny of the legislation. I hope that this undertaking will be welcome to noble Lords and will indicate the Government's strong desire to provide maximum clarity on these matters at an early stage. Therefore, I hope that noble Lords will feel able not to press those particular amendments.
	The noble Lord, Lord Kakkar, and the noble Baroness, Lady Finlay, have tabled remarkably similar amendments-Amendments 133 and 199A respectively-also on the subject of education and training. The noble Lord, Lord Kakkar, wishes to impose a duty on the NHS Commissioning Board to,
	"promote education and training of the health care workforce".
	The noble Baroness, Lady Finlay, wishes to introduce a similar duty on clinical commissioning groups. As I have indicated, the Government's intention is to delegate responsibility for education and training to healthcare providers. They are at the front line of service delivery and are best placed to understand how the workforce needs to develop and respond to the needs of patients.
	Responsibility for education and training is of great importance to employers and the various professional bodies that the noble Lord, Lord Kakkar, mentions in his amendment, but commissioners will also have a role. I agree entirely that education and training needs to be effectively linked with the wider system. I am aware of concerns voiced by the royal colleges and professional bodies on precisely that matter. I wish to reassure the Committee that I recognise the vital interrelationship between education and training, and commissioning decisions. That is exactly why national and local education and training plans will need to respond to the strategic commissioning intentions set out by the board and clinical commissioning groups.
	Similarly, in commissioning decisions there will be a need to consider the implications for education and training-it works both ways. The NHS Commissioning Board has to work closely with Health Education England and it will be a mutually supportive relationship. Indeed, this will be a prime example of the co-operation duties that will apply to the board and to other NHS bodies. Commissioners must also promote and have regard to the NHS constitution, which of course contains the pledges that I have already referred to.
	I do not intend to speak for very much longer but there are a couple of points that I ought to cover. A number of noble Lords pointed to the lack of medical school involvement in the set-up of local arrangements. I need to be clear about this: the new arrangements are underpinned by the desire to strengthen both the provider voice at the local level and the role of professionals and education providers. We envisage that one of the functions of local bodies will be to ensure strong partnerships with universities and medical schools. Providers of services will have to work in partnership; they cannot just sit alone and ignore everybody else. The form of the local provider-led arrangements is still being developed. More details will be available prior to Report, but I have stressed the links that we envisage with academic colleges at a local level.
	I hope that I have indicated that, contrary to the statement from the noble Lord, Lord Warner, that within the modernisation agenda we somehow forgot about education and training, this is not at all the case. As I mentioned when we debated this before, this has been an active programme of work ever since the general election. It is a complex issue and we want to get it right. My noble friends Lord Ribeiro and Lord Mawhinney were spot on in their judgment on this. We are taking action now. We are not losing time over this.
	To sum up, we have made provision for education and training in the Bill. We will publish our detailed proposals before Report and we will publish draft clauses on education and training for pre-legislative scrutiny in the second Session. With those assurances, I hope that the noble Lord will feel able to withdraw his amendment.

Lord Kakkar: My Lords, I thank the Minister for his very detailed and extensive response, which is genuinely welcome. He has dealt with a number of the issues that were covered in this important debate. The confirmation that Health Education England is to be established as a special health authority and that a senior responsible officer has been appointed to drive forward its development at a pace to ensure that it is in a position to fulfil its important obligations and functions is a very welcome announcement. I think it will provide considerable hope that the question of education and training can be fully and appropriately dealt with in such a way that any future legislation can build upon an established structure that has already given confidence to those responsible for education and training that these matters can be properly dealt with.
	The noble Earl has also confirmed a number of other important actions that he and his department propose to take as we move forward with this Bill. His confirmation that draft clauses of any future legislation dealing with education and training will be available for pre-legislative scrutiny and that an understanding around those draft clauses will be provided prior to the Report stage is welcome, as is the confirmation that the work of the NHS Future Forum will also be available to inform any potential discussion that we have in this matter on Report.
	The confirmation that it is envisaged that Health Education England and any local arrangements for education and training boards represent true partnerships-academic service partnerships across the broad discipline, representing elements of the healthcare workforce-is also warmly welcomed. The question of the budget for Health Education England will require further discussion but the confirmation that Health Education England will have responsibility for supervision of the budget for postgraduate education and training is important, as is the recognition that postgraduate deans need to have an ongoing and developing relationship with the universities.
	I wish to address the implied criticism that it was inappropriate to bring this group of amendments at this stage, the Committee having on its first day considered government Amendment 43. As I said at the outset, Amendment 47A and the others in this group were probing amendments to build upon the welcome comments of the Minister on the first day of Committee when Amendment 43 was moved. The Government's approach to specifying in the Bill a responsibility for education and training for the Secretary of State for Health was an important announcement. Many noble Lords felt therefore that probing amendments thereafter to explore the opportunity for the establishment of Health Education England in whatever form to relieve anxieties about the situation described by the noble Lord, Lord Owen, was an appropriate amendment to bring at this stage.
	I am grateful to the Minister for having dealt with these matters with such clarity and in such a way that anxieties around the areas of education and training can now be addressed in a constructive and co-operative fashion with broad support from all parts of your Lordships' House. This will ensure that this vital function is developed for the benefit of patients who need to use our health services by ensuring that we have the best trained healthcare workforce to deliver the highest standards.

Earl Howe: Before the noble Lord decides what to do with his amendment, I should say that I did not wish in the least to imply that this debate was inappropriate in any way. If I did, I apologise. If I may correct one thing that he said, the draft clauses for pre-legislative scrutiny will come forward in the next Session of Parliament rather than before Report. However, we will be publishing much more detail before Report about what our plans will look like.

Lord Kakkar: I welcome those comments. It was not a criticism made by the noble Earl about this but by other noble Lords; there was a suggestion that it was not appropriate to discuss education and training in any detail at this stage. These were probing amendments, designed to provide Her Majesty's Government with the opportunity to address issues, to allay concerns and to allow for further appropriate and constructive evaluation of this matter in the Bill in such a way that noble Lords could fulfil their function of scrutiny and revision to ensure that the best possible Act is finally delivered for the people of our country. With those comments, I beg leave to withdraw the amendment.
	Amendment 47A withdrawn.
	Amendment 47B
	 Tabled by Lord Warner
	47B: After Clause 5, insert the following new Clause-
	"Secretary of State's duty relating to education and training
	(1) The Secretary of State has a duty to provide or secure the provision of an effective system for the planning and delivery of education and training of a workforce of sufficient size and competence to discharge his duties under this Act to ensure a comprehensive health service.
	(2) In discharging this duty, the Secretary of State must establish a body known as Health Education England and this body will be responsible for the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries.
	(3) The budget for this body and its functions should be calculated on the basis of a formula related to the total health service expenditure and initially should be no less than the level of expenditure on education and training at the time of Royal Assent."

Lord Warner: My Lords, I am grateful to everybody who has spoken in this debate. I particularly welcome the support given by the most reverend Primate and by the noble Lord, Lord Owen. I share the scepticism of the noble Lord, Lord Owen, about next-Session legislation and we would all do well to think carefully about his remarks.
	I am still rather puzzled about why, if the Government are prepared to set up Health Education England as a special health authority, they cannot put it in the Bill along the lines of Amendment 47B. By all means doctor Amendment 47B. It was not the purpose of Amendment 47B to unreasonably tie the hands of the Government but I am still struggling with the question of why, if the Minister is prepared to produce a detailed paper before Report in which he agrees to set up a special health authority by next September, we cannot have a sensible cross-party discussion about setting up Health Education England in this Bill and giving the Government the necessary powers to make regulations to fill in the details.
	My ears pricked up on the subject of money when the noble Earl said that there would be a "robust analysis". I am willing to open a book on how far south of £4.9 billion the Government end up with on the robust analysis on education and training. I am available at all hours to discuss the odds a little further on this issue.
	I will study the noble Earl's remarks carefully. I listened carefully to what he said. He has moved some way. Whether he has moved sufficiently far to stop us bringing forth an amendment on Report is in doubt.
	Amendment 47B not moved.
	Clause 6: The NHS Commissioning Board

Baroness D'Souza: I must advise your Lordships that if Amendment 48 is agreed to I cannot call Amendments 49 to 51 by reasons of pre-emption.
	Amendment 48
	 Moved by Lord Hunt of Kings Heath
	48: Clause 6, page 3, leave out lines 27 to 34 and insert-
	"(2) The Board has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act and subject to any directions issued by the Secretary of State.
	(3) The Board must exercise the functions conferred on it by this Act in relation to clinical commissioning groups so as to secure that services are provided for those purposes in accordance with this Act.
	(4) The Secretary of State may give a direction to the Board to discharge each of those functions, and in such manner and within such period or periods, as may be specified in the direction."

Lord Hunt of Kings Heath: My Lords, we come to a very important matter-the role and function of the national Commissioning Board. It is almost as important as the previous debate on the responsibilities of the Secretary of State.
	In a telling intervention last week, the noble Lord, Lord Marks, spoke of the tension in the Bill between the proposed duty to promote autonomy on the one hand and the fulfilment of the Secretary of State's overall responsibility for securing the provision of services on the other. I suspect there is a similar tension built into the Bill in terms of the relationship between the Secretary of State and the national Commissioning Board.
	At the heart of this debate have been concerns about the alleged micromanagement by the Secretary of State into the affairs of the National Health Service and specifically with regard to reconfiguration decisions. I sympathise with those in the NHS who can feel frustrated if hard-worked-through proposals are held up or rejected by Ministers or the service is constrained by too many interventions and targets from the centre. To think that this can simply be waved away in the new structure may prove to be optimistic. I suspect that a confusion of responsibilities between the Secretary of State and the national Commissioning Board and the plethora of organisations the Government have established or proposed to set up may well add to the burdens of the NHS.
	Why is there political intervention in the health service? Surely there is political intervention because the NHS is one of the most important services that the Government are called upon to deliver to the public. Surely there is political intervention because, in the end, the public require it. In our debate last Wednesday the noble Lord, Lord Mawhinney, said that the public, for whom the NHS exist and who pay the NHS bill, expect politicians to intervene on their behalf. Indeed, democracy may be a messy process but I prefer a messy process to rule by quango or even an unaccountable group of clinicians.
	Even if you succeed in removing the Secretary of State from the picture, is it likely that local NHS organisations will simply be left to get on with life without external interference? The public will certainly not go away and nor will their representatives, Members of Parliament. They will still encourage the Secretary of State to intervene in the health service. Even if the Secretary of State courageously resists that pressure, it will then fall on the national Commissioning Board. I doubt that the regulators, the CQC and Monitor, will be immune. Nor, I suspect will clinical senates, the health and well-being boards that will be established or the commissioning support units that are apparently to emerge up and down the country. Certainly, clinical commissioning groups themselves will not be immune.
	The idea that if you remove the Secretary of State from reconfiguration proposals all will be sweetness and light, with rational bodies making rational decisions and a grateful public acquiescing to those decisions, does not seem to be in the real world. Is it really suggested that £120 billion of public money does not require full accountability of Ministers to Parliament? By full accountability I mean sole accountability, rather than the construct of this Bill, which quite remarkably gives the Secretary of State and a quango-the national Commissioning Board-concurrent powers in relation to the crucial duty in Clause 1. It is so important that the Secretary of State is solely accountable because that is probably the best protection of the overriding mission of the health service to provide comprehensive services to all.
	I recently read the transcript of the evidence that the chairman of the national Commissioning Board, Professor Grant, gave to the Health Select Committee, which is very interesting. Professor Grant disarmingly described the Bill as "unintelligible" but we know that all Bills, on the face of it, look rather unintelligible. He went on to make much of the Secretary of State's responsibility for delivering, as he put it, a comprehensive NHS. He then laid great stress on the mandate set for the board by the Secretary of State. He suggested that it should be for three years, rather than an annual mandate as laid down by the Bill. He made it clear that if,
	"the matter is within the mandate of the Board, it is not within the jurisdiction of the Secretary of State, except that he has power to revise the mandate with the consent of the Board or ... in exceptional circumstances",
	he can intervene. The professor concluded that,
	"ultimate political accountability ... remains secure, but it requires a Secretary of State to define upfront what he or she wants the Board to be accountable for and to hold the Board accountable for it".
	I found that, from the chair of the NCB, eminently sensible and I have no criticism to make of the points that he put forward. However, does that reflect the real world? Things happen, reports are published and crises occur. The Secretary of State cannot simply wash his hands of responsibility. There will be occasions when, mandate or no mandate, he will want to intervene.
	A number of today's newspapers carried stories that indicate that the Secretary of State is prepared to sack PCT chairs if they continue to save money by rationing treatments or making patients wait longer for operations. I do not know whether that is true but I say to the noble Earl that I certainly make no complaint about Mr Lansley's actions. It seems entirely appropriate for the Secretary of State to wish to intervene in that kind of event. However, what would happen if the Bill were to be enacted? Let us say that continuing financial pressures led clinical commissioning groups to implement a 15-week wait for non-urgent treatment, or that patient choice was restricted to ensure that sufficient money flowed into the local hospital to ensure its continued viability. Assume then that MPs raised complaints about that in Parliament to the Secretary of State, and that the Secretary of State wanted to intervene. How? Would he call in the chair of the national Commissioning Board? Would the chair say, "I'm afraid that's an operational matter-nothing to do with you, Secretary of State. It's not in the mandate". In any case, the chairman of the national Commissioning Board might go on to say, "You set the NCB one of its main goals, which is to balance the books of the health service. If we take action in the way you want, the books won't be balanced". What happens then? I suspect that there will be a huge tension and tussle, with real confusion in the NHS and among the public as to who is in charge.
	Coming back to my Home Office brief, in the past two weeks we have seen some of the problems that can arise between a Secretary of State and an executive agency such as the UK Border Agency. There is absolutely no question that the UKBA is a subordinate agency of the Home Office. Therefore, there is no question over the Home Secretary's right of intervention. Whether she intervened correctly is, of course, another matter. How much more confusion will there be if you establish a hugely powerful quango and give that body the same, concurrent duties as the Secretary of State in relation to the crucial duty set out in Clause 1?
	I wish Lord Marsh was still here to talk about his experience in the nationalised industries. He was both Minister for and chairman of British Rail. Those of us who can recall those heady days will remember the inevitable tension between the Minister and the chairman of the nationalised industry. We certainly saw day-to-day intervention by Ministers in rail, steel and the other industries. We also saw a great deal of resentment on behalf of the chairmen of the boards of those industries. My suggestion is that the same is likely to happen over the NHS between the Secretary of State and the national Commissioning Board. That is why the relationship between the NCB and the Secretary of State is so important. Amendment 48 goes to the heart of this by removing the proposal in Clause 6 that the Commissioning Board should have concurrent powers with the Secretary of State in relation to Clause 1. I know that the Government have invited noble Lords to withdraw all their amendments to Clause 1 to allow for further discussions. I hope that the noble Earl will agree to do the same in relation to Clause 6.
	The NHS Commissioning Board, however well led and powerful it is, ought not to be given the same, concurrent powers as the Secretary of State. There should be a clear hierarchy and the hierarchy should be the clear accountability of the Secretary of State. In Clause 1, clear responsibility should be given solely to the Secretary of State. That would therefore mean that the Secretary of State would have full power of direction over the national Commissioning Board. That would establish a sensible priority and ensure that clear accountability to Parliament through the Secretary of State is maintained. Above all, it would give clarity to the National Health Service. I beg to move.

Lord Mawhinney: My Lords, I too want to focus on line 27 of Clause 6:
	"The Board is subject to the duty under section 1(1) concurrently with the Secretary of State".
	This raises all the issues that we have debated at length. I know that the Minister has taken away Clauses 1, 4 and 10, but, as the noble Lord, Lord Hunt, said, it would be extremely helpful to the Committee if he agreed to take away Clause 6 as part of the package on which to consult. Otherwise, those words in the Bill continue to provide a fault line that at some point will need to be addressed. I hope that my noble friend feels that it would be more productive to address this point in the spirit of co-operation and cross-party support that he has engendered for Clauses 1, 4 and 10 and include Clause 6 as well.

Lord Warner: My Lords, I rise to speak on this amendment, mainly because of my puzzlement over why the Government want to give the national Commissioning Board a concurrent duty with the Secretary of State under new Section 1(1), given all the other provisions in the Bill which try to shape-if I may put it that way-the relationship of the Secretary of State with the national Commissioning Board. This is especially the case with Clause 20, the mandation clause. One interpretation of this concurrency is that the Secretary of State can pick and choose how he interprets his responsibility.
	My noble friend Lord Hunt has mentioned, as delicately as he could, what has happened in the Home Office recently about the sometimes rather strange boundary between policy responsibility and management responsibility and the confusions that could arise. This is not the first time that the Home Office has got into this kind of territory. Your Lordships will remember the difficulties that Michael Howard, when he was Home Secretary, had with the chief executive of the Prison Service, Derek Lewis. It boiled down to this problem of uncertainty about where the remit of Ministers ended and where responsibility began, in this case with the Prison Service, an executive agency. Equally, though, I suggest it could have been a non-departmental public body.
	There is a lot of history in this area where one should be extremely wary about passing legislation in particularly high-profile areas and giving concurrency of responsibility to a Secretary of State and to a powerful arm's-length body, in this case a non-departmental public body, the national Commissioning Board. It is fraught with difficulties. I thought that the Government were trying to clarify this with Clause 20. I think the clause has been misunderstood a little bit by the new chairman of the national Commissioning Board, but the wording as it stands gives the Secretary of State the right, before the beginning of each financial year, to set out a mandate for the board.
	There are a lot of safeguards in Clause 20, on both sides of that discussion and agreement. The national Commissioning Board has a lot of safeguards. The Secretary of State cannot keep coming back and adding bits and pieces as the year progresses. The Secretary of State also has quite a lot of safeguards. He or she can expect the national Commissioning Board to stick to what has been agreed in that mandate. There is no doubt about the Secretary of State's ability to give instruction to the board and there is no doubt about his ability to change those instructions on an annual basis after proper discussion and consultation. That is very clear. One of the strengths of Clause 20 is that it does make the relationship clear between the Secretary of State and the national Commissioning Board.
	I have tabled an amendment that tries to restrict the number of requirements that the Secretary of State can place on the national Commissioning Board. I can well remember the time when the noble Lord, Lord Mawhinney, was a Minister with responsibilities for health, along with his colleague the noble Baroness, Lady Bottomley, who is not now in her place. We had somewhere in excess of 50 priorities in the NHS that we were required to deliver each year. In practice, we had no priorities, because no one could hold 50 priorities in their head, so there is an issue about how far you go on mandation. Nevertheless, the structure of Clause 20 clearly states what that relationship is, on an annual basis, between the Secretary of State and the national Commissioning Board.
	We would do well to stick with that kind of relationship rather than muddy the waters with a concurrency of responsibility. I will be interested to hear what the Minister has to say on this issue.

Earl Howe: My Lords, as has been pointed out, this amendment returns us to the topic of the comprehensive health service. We have had a wide-ranging debate on that issue. I appreciate the concerns held by some noble Lords about the extent to which the Secretary of State will be genuinely accountable for the health service under the new arrangements introduced by the Bill. I have outlined the reasons why I believe accountability will be maintained and how accountability to Parliament and the public will be increased by our proposals. We have indicated our intention to look further at what could be done to put the Secretary of State's ultimate accountability for the health service beyond doubt. We will do that.
	However, it is a core principle of our reforms that politicians should step back from day-to-day interference in the NHS to allow clinicians to take the lead in developing services that are built around the needs of patients. That would simply not be possible if the Secretary of State retained broad powers of direction over the NHS Commissioning Board. As I have previously described, the role of the Secretary of State in future should be to set the legislative and regulatory framework; to set the strategic direction for the NHS through the mandate, as the noble Lord, Lord Warner, has rightly reminded us; and to hold the national bodies in the system to account for fulfilling their responsibilities effectively.
	I also understand the argument that the Secretary of State alone should be responsible for promoting a comprehensive health service. However, I believe that there are strong arguments that, in the interests of accountability, the NHS Commissioning Board should share this duty as far as it relates to NHS services. The NHS Commissioning Board will be the body responsible for ensuring that there is a comprehensive coverage of clinical commissioning groups covering every area of the country. It will be responsible for authorising and assessing clinical commissioning groups, providing support and guidance to them, and intervening if they run into difficulties. It falls to the NHS Commissioning Board to ensure that the continuity and quality of service provision is maintained at all times.
	I am afraid that the arguments of the noble Lord, Lord Hunt, expose a clear fault line between the Government and the Opposition. We believe it is important that the board should be under the same obligation as the Secretary of State to promote a comprehensive health service in so far as this relates to the health services that the board and clinical commissioning groups will be responsible for. Let me be clear: the Bill's provisions would in no way dilute the Secretary of State's overarching duty. Indeed, they are intended further to reinforce the promotion of a comprehensive health service rather than to undermine it. With the general desire of noble Lords to strengthen accountability in the Bill, it seems odd that the noble Lord, Lord Hunt, should want to weaken accountability in this way, for that is what his amendment would do.
	I listened to the point made by my noble friend Lord Mawhinney that this is another facet of the issues that we are going to consider in relation to Clauses 1, 4 and 10. He made a good point. Therefore, I suggest that, in the light of our intention to consider together how we approach the duty on the Secretary of State and return to this on Report, the amendment should also be withdrawn and that any consequential changes to the functions of the board or clinical commissioning groups are considered as part of those deliberations.
	I have omitted to cover a number of points made by the noble Lord, Lord Hunt. He referred to minimum waits and restricting patient choice. Of course, the mandate on the standing rules would allow for specific requirements. For example, they could be used to prohibit minimum waits, and it is very likely that they will be used for that purpose. The Secretary of State would be able to set that kind of direction in order to achieve that. Patient choice could form part of the mandate. It is also something that Monitor would look at. The purpose of the mandate is to set out exactly what the Government expect from the NHS. It is intended to provide the clarity that the noble Lord and, indeed, most other noble Lords, would seek for the NHS Commissioning Board's remit.
	I do not think that the noble Lord has made his case; in fact, far from it. It would significantly weaken the Bill if we were to go down the road that he is suggesting. I once again ask him to give further thought to this issue before pressing it any further.

Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Earl for his response. I am, of course, very happy for this to be considered in the light of the debate in relation to the other clauses around the Secretary of State's powers. I may not have convinced the noble Earl but he has convinced me that a "train crash" will inevitably occur given the ambiguity and confusion built into the Bill on the role of the Secretary of State and the national Commissioning Board. The more the noble Earl spoke about that, the more evident the ambiguity became. As regards the mandate, my noble friend's amendment suggests that only five functions should be given to the national Commissioning Board with five other objectives. I think that he is supported in that by other noble Lords. He has probably forgotten about the innate ability of the wonderful civil servants at the Department of Health to write very long functions which could probably embrace the world. However, I understand where he is coming from.

Lord Warner: I well understand the Civil Service's ability to use the semicolon to extend a sentence for a very long period.

Lord Hunt of Kings Heath: My Lords, my noble friend should refine his amendment by limiting the number of grammatical devices that can be used.
	I raised this matter because of what the noble Earl said. I raised the reported intervention by the Secretary of State in relation to primary care trusts and the concern that because of their financial issues they are essentially putting in some artificial barriers in relation to patient treatment such as having a rule that on non-urgent treatment you have to wait a certain length of time before you can be treated, and other such mechanisms. When I asked the noble Earl how this would work in the future, he told me that it would be put in the mandate. Clearly, what will happen-

Earl Howe: I am grateful to the noble Lord for giving way. If the board was not delivering the mandate, it is surely right that the Secretary of State should intervene. He has powers in the Bill to do that. Equally, if it is delivering the mandate, it is also right that it should be allowed to get on without interference from the centre. All we are saying is that the Secretary of State should be clearer about the reasons for his intervention in future. That is in everybody's interests.

Lord Hunt of Kings Heath: Either the mandate is so detailed that you will have reams of paper telling the board what to do or the Secretary of State will rightly become concerned at issues that arise during the year. Those issues will not be covered by the mandate as they will not have been anticipated. The Secretary of State will wonder what to do and how to intervene. He will wonder whether he will be told by the national Commissioning Board, "Back off. It is nothing to do with you", as nationalised industries used to do. This is no different from a nationalised industry. I am concerned because I believe that giving concurrent powers to the national Commissioning Board as well as to the Secretary of State will lead to a great deal of confusion, tension and ambiguity. At the end of the day I would prefer one person to be accountable-the Secretary of State. However, I am encouraged by what the noble Earl said about agreeing to look at this in the context of the other questions about the duty of the Secretary of State. I beg leave to withdraw the amendment.
	Amendment 48 withdrawn.
	Amendment 49 not moved.
	Amendment 50
	 Moved by Lord Warner
	50: Clause 6, page 3, line 38, at end insert-
	"( ) must include at least one member who is a registered public health specialist and who has a broad range of professional expertise in public health"

Lord Warner: My Lords, in the unavoidable absence of my noble friend Lord Rooker, he has asked me to move Amendment 50 standing in his name and those of a number of colleagues. This amendment is very simple in intent. It seeks to ensure that the national Commissioning Board has at least one member who is a public health specialist. Much of the work of the board and, indeed, of the clinical commissioning groups, is to commission services that arise from failures of public health, or the associated issue of the absence of clinical intervention at an early stage in a person's condition. Later we will discuss a raft of amendments for strengthening the Bill's provisions on public health itself. This group of amendments is concerned with the membership of the national Commissioning Board and the disclosure of information.
	This amendment is intended to help the board in its deliberations. It is essential that it has ready access to public health expertise. I very much support Amendments 153ZA and 153B in this group, standing in the names of my noble friends Lord Hunt of Kings Heath and Lady Thornton, which seek to curb the administrative costs of clinical commissioning groups. I have degrouped my amendments on controlling the overheads and management costs of the board. I have also tabled amendments that try to curb clinical commissioning group management costs. I tabled these amendments because I wanted to ensure that we had a fuller discussion on the two linked issues of overheads and administrative costs at a later stage. I will not speak on that issue at length today but I want to flag up to the Minister that this is an extremely important issue in this very difficult financial climate. Rather unusually, we may need to put in a Bill establishing new bodies a curb on the extent to which they can grow their administrative budgets in the future. My noble friends are doing the House a service in giving us a chance to have a debate on this issue.
	I return to Amendment 50. It may not be directed at the right place in the Bill-I leave the Minister to think about that-but its substance should be in the Bill. I hope that the Minister will reconsider the Government's position on this issue. I beg to move.

Baroness Finlay of Llandaff: My Lords, I rise to speak to this amendment, which is also in my name, and to support the other amendments in this group. They have the effect of ensuring that public health considerations and public health expertise are given due weight in the new arrangements set out in the Bill.
	Public health covers three main domains: health improvement; health protection; and health service delivery. Public health specialists are trained and skilled in interpreting data and information about populations, understanding health needs and securing the services required to meet those needs. That expertise is vital to having effective commissioning at every level, particularly that of the NHS Commissioning Board, which will have the overarching responsibility for commissioning health services, so as to ensure that the services are effective, appropriate, equitable, accessible and cost-effective. It therefore seems only sensible to make sure that that expertise is incorporated at board level.
	The Commissioning Board exists to secure and improve the health of the population through the NHS services it commissions, and indeed through the services which are not NHS-provided, if I have understood this Bill correctly. To do this, the board would benefit from public health input. Public health specialists have an unparalleled overview of a community's need for health services and how they are best commissioned, including changing, adapting or even decommissioning services which could work better in other ways. The role of a public health specialist would also be to provide the essential expertise needed to commission preventive services, such as screening and immunisation, and to look at the evidence relating to those services. The board may need the courage to decommission some of those services as well, or to substantially alter the way that they are delivered.
	It would be inappropriate to say that this is going to be too expensive, because a public health specialist should pay for themselves many times over with their presence on the board. It is only by having such an expert at board level that we can their ensure expertise is incorporated into decision-making, rather than only feeding into the process in an advisory capacity.

Baroness Williams of Crosby: My Lords, one of the most interesting aspects of the proposals in this Bill is the greater status to be given to public health. I think we all recognise that for some years public health has been something of a Cinderella in the medical establishment. To have public health lifted, as it should be, on to board representation seems to me absolutely central in our attempt to put greater accent on prevention, education and information; there are future amendments by some of my noble friends on some of those issues. I wish to say very briefly that I think that this amendment is absolutely right. It is crucial that public health recognition is given at board level, and I hope we can echo that in having it also represented in the clinical commissioning groups as they emerge.
	One other question to raise in relation to public health, which we have been considering very carefully, is how we deal with chronic illness. Chronic illness is obviously not unrelated to lifestyles and life behaviour, so here again, raising the influence of public health in the attempt to bring about a healthier lifestyle among our fellow citizens and ourselves is absolutely essential. I therefore completely agree with what has been said by the noble Baroness, Lady Finlay, and the noble Lord, Lord Warner, in moving this amendment: that it is vital that public health be represented at the highest level.

Lord Patel: My Lords, I have added my name to the amendment, and I strongly support it. It is absolutely crucial that a public health specialist is a member of the NHS Commissioning Board. I note that protection and improvement of public health is one of the two crucial functions imposed upon the Secretary of State for Health by the Bill, and in several places. Three different bodies will be involved in discharging this function: the board, the commissioning groups, and local authorities. It is therefore essential that each has a public health physician at board level to do so. Effective commissioning requires expert understanding of populations and the diseases they might get, as well as their health needs and how these can best be met.
	There are major public health roles for the NHS Commissioning Board, including the direct commissioning of services, for which public health specialists' expertise needs to be embedded in the board's management structure. The NHS Commissioning Board will continue to manage primary care contractors, hold the population registers which make screening programmes possible-as the noble Baroness, Lady Finlay, mentioned-set the policy direction and operating framework of the NHS, and oversee major commissioning decisions and plan commissioning groups.
	Without a registered public health specialist as an integral member of the NHS Commissioning Board, national commissioning decisions will be made without an expert population health perspective informed by clinical and population-based data. It is critical that public health expertise informs all commissioning decisions and that commissioners have access to timely, reliable and relevant information and analysis. To meet this need, it is crucial that there is a registered public health specialist on the board of every health commissioning board, including the NHS Commissioning Board.
	There are other issues. Public health expertise within the service is also essential if the escalating costs of low-benefit technologies are to be controlled and the health service commissioners are to have the knowledge to implement the most effective and lowest-cost services. There should also be a duty placed on commissioning organisations to work with directors of public health and the public health teams on all commissioning decisions to ensure they meet the health needs of their communities. In addition, health impact assessments, and especially health inequalities impact assessments, are needed in all commissioning group investments in healthcare and in all clinical care pathway design. Where different care options exist, it is necessary to model which intervention will deliver the greatest health improvement for the lowest cost. Public health specialists are trained to do this, and to not have them at the board level of every commissioning body, including the NHS Commissioning Board, would be wrong.
	I know that there is a later amendment which proposes that, if there is a member of the executive or a civil servant with public health expertise on the board, the current amendment might not be necessary. I do not agree. I think it is absolutely necessary that the public health specialist on the board is there independently, to give an independent view.

Lord Rea: My Lords, I support all those noble Lords who have spoken so far and I agree with everything they have said; there is hardly anything for me to add. I just want to emphasise that a public health specialist will have had special experience and training in dealing with the massive amount of health data that comes into a health authority or, in this case, to the NHS Commissioning Board; it will be a huge amount. Public health specialists are trained in statistics and in epidemiology, and have other skills needed to handle this information and to help the board to make the correct decisions. I would like to emphasise the point made by my noble friend Lord Warner that very often this can be extremely helpful when certain services are deemed no longer appropriate. They may save a lot of money by giving backing to decommissioning and reconfiguring certain services, ensuring that populations are best served with the resources that are available.

Baroness Jolly: My Lords, it sounds as though there is a considerable level of agreement on this. I, too, believe that we should have a public health specialist sitting on the board. Members of the faculty have said that if there is not going to be such a specialist on the board by right, there should at least be one where the CMO is not a public health specialist. This Bill has put public health at its core and at every level.
	I shall not say any more about the public health appointment but I will talk a little about the involvement of the patient. The patient is also meant to be fundamental to this Bill: "no decision about me without me." Again, we have the patient involved through local government and the local commissioning groups but not necessarily on the board. I think that whoever is chair of HealthWatch England should have a seat on the board.
	What would both of these positions bring to the board? They would bring a level of expertise that nobody else has. I understand the Government's reluctance to be specific, and I know that lists are problematic. I also know that with these things there is a tendency to request that every man and his dog, or all and sundry, sit around the board table. However, it is a board table and not a representative council, so I would put those two people there for one distinct reason: they add a dimension that the board does not know it misses. Decisions made without them will be made in a vacuum and will be all the poorer for it. Somebody put it to me earlier today-your Lordships will have to excuse me for this-that the board knows what it knows, it knows what it does not know, and it does not know what it does not know.

A noble Lord: Was it Donald Rumsfeld?

Baroness Jolly: Apparently there was a Persian poet who got there even before him, but whether Donald Rumsfeld was a reader of Persian poetry, I know not. The point is that you do not know what you do not know. Both those voices would bring to the board serious added value.
	I have another four or five amendments in this group which relate not to the composition of the board but to its work. Every year, the board is tasked with producing a three-year business plan on how it is going to discharge its functions. We have a Secretary of State who produces a mandate for the board. We are all in total agreement that the board has huge powers to shape the NHS. New Section 13S of the 1996 Act indicates that there should be an ability to revise the plan. It talks about a "revised plan" but says nothing about the process of revision. The Bill is silent also on the operational plans of the board. I am slightly curious as to which comes first-the mandate or the plan.
	How might a conversation with patients and other stakeholders be managed to revise the draft plan? Clearly, we have to start with a draft and then it will be revised. To what extent does the Minister envisage the plan being amended? Might the details on board membership and business plan consultation be included in guidance to the board? One half of my amendments is about board composition; the others are about business planning. It will be interesting to hear the Minister's response to the latter because it will give us some indication of the way that the board plans to work or it is planned that it should work.

Lord Hunt of Kings Heath: My Lords, I have a series of amendments in this group concerning membership of the national Commissioning Board and its cost. There is common consent that getting the board's membership right is important.
	My Amendment 52A would ensure that the chair could be appointed only with the consent of the Health Select Committee. I fully acknowledge that Professor Grant, the chair of the NCB, went before the Health Select Committee; I have already referred to the transcript. It is clear that the process ensured proper and effective scrutiny. However, I should just like to put the matter beyond doubt and make sure that the procedure will always be followed in future, and I hope that the Minister will agree to my amendment. I should say that I followed the legislation which established the Office for Budget Responsibility, so we have a precedent for ensuring that a Select Committee of the other place has an important role to play in such appointments in the future.
	My Amendment 52B is simply a matter of good governance to ensure that a lay vice-chair is appointed, which I am sure I am right to assume is the Government's intention.
	On the composition of the board, my Amendments 54 and 56 are intended partly to probe and partly to make a point. It would be helpful if the Minister could give some indication of the likely make-up of the board, both executive and non-executive, and perhaps some details about how non-executives are to be appointed. My specific point is to encourage the Minister to ensure that, on the executive side, a medical director, a nursing director and a finance director are always appointed. To be frank, my main focus is in relation to a nursing director. I have no doubt that there will always be a finance director and a medical director; I want to ensure, and I want the Minister to give an absolute assurance, that there will always be a nursing director on the national Commissioning Board. I go back to 1991, when NHS trusts were first appointed. Some noble Lords here will recall that some rather foolish chairs of those trusts did not want to appoint a nurse to their board. They were forced to do so, I am glad to say, through the intervention of a Secretary of State at the time. I have no doubt that it is the intention of the Government to ensure that there is a director of nursing on the board, but I should like to make sure that it always happens.
	I understand that getting a range of expertise on the non-executive side will always be difficult. As the noble Baroness, Lady Jolly, said, the risk is that Parliament will always seek to legislate for a list of backgrounds, which we know is not a practical way to ensure that a fairly small board is appointed. My amendments seek to ensure that there are at least some non-executives on the NCB who have some experience of the National Health Service. While the temptation will always be to appoint people from other sectors because of the experience that they can bring, there is something unique about the National Health Service. I think that non-executives find it helpful if, among their number, they have people who know the business and help them to challenge the executives. One of the risks of the fashion-my own Government were as guilty of it as any other-of thinking that what the health service most needs is outside business expertise is that, when it comes to issues of safety and quality, you do not have anyone on the non-executive side who can effectively challenge the executives. I urge the Government to ensure that there are non-executives on the board who have real experience of the National Health Service and how it works in order to enable a proper challenge to be put to the executive directors.
	Amendments 52D and 54A are probing amendments, designed to tease out the place of public health on the national Commissioning Board. I support the comments already made by noble Lords. On my proposal that the Chief Medical Officer be a member of the board, the Minister may say that he thinks it more appropriate for the Government's chief medical adviser to be seen purely as part of the department than to be on the national Commissioning Board. I sympathise with that point. I suspect that the answer to the question of the noble Baroness, Lady Jolly, in relation to HealthWatch is that there is always a problem if people are appointed because of their other positions. The problem is that they then have to take responsibility for the corporate decision-making of the NCB. I can therefore assure the Minister that my amendment to place the CMO on the NCB is probing, designed to enable us to hear how the public health function will be given sufficient prominence within the national Commissioning Board.
	My Amendment 55 would remove the requirement for the appointment of the chief executive to be approved by the Secretary of State. I have no problem with paragraph 3(4) of Schedule 1, which provides for the first chief executive to be appointed by the Secretary of State. This is normal practice and is entirely sensible in view of the need to get the national Commissioning Board up and running. However, my question is why the Secretary of State needs those powers in relation to subsequent appointments. After all, the Minister has waxed lyrical about the need for there to be distance and for the Secretary of State no longer to intervene, so why on earth does he have to approve the appointment of a chief executive? Surely that is for the board to do. Surely it is for the Secretary of State to nominate the chairman of the board to go through the necessary parliamentary scrutiny. For the Secretary of State to actually have to approve the appointment of the chief executive is ambiguous. The department has not sorted out the real relationship between the Secretary of State and the national Commissioning Board. On the one hand, there is the desire to give the NCB as much freedom as possible; on the other hand, one knows that in these clauses there is a desire to control it. I should have thought that the fact that the Secretary of State has a veto over the chief executive appointment is an example of that. I hope that we can see that go between now and the conclusion of our proceedings on the Bill.
	Finally, I come to some probing amendments concerning the number of staff to be employed by the national Commissioning Board and the staffing. I should like to hear from the noble Earl something about the size of the NCB and what its regional and local structure is likely to be, remembering that it will hold the contracts of thousands of practitioners. My understanding is certainly that it will hold the contracts of all GPs because it is deemed that presumably the local clinical commissioning groups cannot hold the contracts of the GPs who are members of the clinical commissioning groups. Clearly, if the Government's proposals are to streamline decision-making, then finding that the national Commissioning Board becomes an absolutely huge organisation with thousands of people employed will rather detract from what the Government seek to do. It would be very helpful if the Minister could give assurances about the cost of the NCB.

Baroness Masham of Ilton: My Lords, I should like to go back to Amendment 50 and, in supporting this amendment, to tell your Lordships that during the deliberations of the House of Lords Select Committee on HIV and AIDS this very subject came up. It was felt to be essential that a public health specialist should sit on the Commissioning Board. Also, I feel that he or she should be the link between the NHS and the local authorities. Public health needs to have a high profile. It is vital to have someone who understands the problem of sexually transmitted infections-in which we lead Europe-as well as PVL MRSA, which is a community-type MRSA, food poisoning and epidemics such as flu. It could be possible for somebody who was interested only in obesity and exercise to be put on the board. Our public health is vital.

Baroness Murphy: My Lords, this is a very large group of amendments and I take them in the spirit that they are mainly probing. One cannot help but be sympathetic to the intention to have public health expertise available to the Commissioning Board, as well as the patient's view and all those other things. The professional point of view is vital.
	I speak as someone who was the only NHS non-executive on the Monitor board for many years before I recently ended my term of office. I am also very sympathetic to the idea that there should be an external non-executive person on the board. Having said that, I think that the noble Baroness, Lady Jolly, and the noble Lord, Lord Hunt of Kings Heath, have mentioned that what we have here is a corporate board, not a representative committee, and a relatively small board. Therefore, it is vital that we do not put on the face of the Bill the number of people who we would like to see have an impact on this board. I look forward to hearing how the noble Earl responds on how we can address these concerns.
	I strongly support the amendment of the noble Lord, Lord Hunt of Kings Heath, and the noble Baroness, Lady Thornton, about having a senior independent director on the board. I have seen how extraordinarily valuable that role can be in foundation trusts and, indeed, on the Monitor board. A little holding to account of the chairman by the non-executives through that senior independent director-a powerful second person on the non-executive front-gives the board great added strength. I support that amendment, although a deputy could well play that role. I certainly support the thrust and meaning of these amendments but I would not like to see them written into the Bill as they are.

Baroness Cumberlege: I would like to support the noble Baroness, Lady Murphy. It is really rather a mixed bag of amendments that we have before us. Clearly what is proposed in the Bill is that there should be 11 members on the NHS Commissioning Board. Perhaps the most wonderful Primate-I hope that Hansard will allow me to make the change-and the right reverend Prelate will think that the number 11 has a certain resonance about it, historically and religiously. We will leave it at that.
	What I wanted to address was the size of the board and what has been said about whether it should be representative or whether it should be left to the board to decide the skills and experience that it needs to act effectively. I saw in the amendments-sadly, he is not in his place at the moment-that the noble Earl, Lord Listowel, suggested having a director or a previous director of children's services on the board. I can fully understand that because the noble Earl has done so much to try to promote the well-being of children. Clearly he feels that it is a constituency that needs to be represented on the board.
	Other people might think that perhaps we need a past director of adult services on the board, especially as we have an increasingly elderly population. I can think of other professions which may ask where on the board are the pharmacists, the podiatrists, the physiotherapists, the occupational therapists and the dentists. We could have a litany of people who wanted to be on the board, so we have to be very careful.

Lord Warner: I think that the noble Baroness is experienced enough, like me, to remember the 1974 reorganisation of the NHS, where we ended up debating whether area gymnasts should be appointed. Therefore, I have every sympathy with her particular line of argument.

Baroness Cumberlege: My Lords, I am very grateful for that intervention. I have no experience of gymnasts and, sadly, I cannot remember that particular time. However, I have chaired very big boards. I have chaired a board of 26 and it was a nightmare. It was a nightmare because we are such a lovely nation and we always try to get consensus. Trying to do that takes time and tough and speedy decisions are not taken. In the end, the board loses the grip necessary to manage the service, the organisation or whatever it is in charge of. Therefore, I strongly support my noble friend on the issue of having 11 members on the board. When one has a very large board, a clique forms; one gets a few people who in the end run the board. They run it outside board meetings. They make the decisions before they come to the board. One gets a body of people who are responsible on the board but are actually disenfranchised-they are accountable but disenfranchised-and I think that that makes the board totally dysfunctional. Therefore, we should resist the temptation to have representatives on the board. We need a chairman with considerable leadership skills; a chief executive of proven management expertise; executives who know the business; and non-executives who bring a breadth of experience.
	I have some sympathy with the arguments that have been put on the issue of the Director of Public Health but I wish to reserve my position on that, as I do on the suggestion put forward by my noble friend Lady Jolly on HealthWatch England, because it could be that the board, or whoever, might decide that there is a non-executive who has wider experience and possibly could be more effective on the board than the chairman of HealthWatch England. This needs discretion and we should leave it in the hands of the board and the Bill and not try to make it representative.
	In an earlier debate the noble Lord, Lord Davies of Stamford, who is not in his place today, referred to the "fatal tendency" of the NHS to be bureaucratic and exercise producer catch-up. He said:
	"the tendency of any organisation that is in a monopolistic position [is] to be run for the convenience and in the interests of those who are providing the service, whether doctors, nurses, managers or whatever".-[Official Report, 9/11/11; col. 251.].
	We have to be very careful that we do not fall into that situation and we must try to address that "fatal tendency", as he described it.
	I wish to make one comment on the seductive amendment on limiting the numbers to be employed to 500. That again is a mistake. If we set a number, it is very likely that that number will be reached where possibly only 100 are required. It needs a great deal of scrutiny by the Secretary of State and others, through the mandate, to see what the board is doing and whether it is effective and keeping to its budget, which I am sure will be closely watched. I would like to keep the number on the board to 11.

Lord Harris of Haringey: My Lords, it is always a pleasure to follow the noble Baroness, Lady Cumberlege. She and I have sat opposite each other at meetings for more years than I care to remember.
	However, her belief that the chair of the NHS Commissioning Board will only be able to manage a board of 11 is slightly misplaced. We already know that the person who holds this office will be able to walk on water, with due deference to the most reverend Primate. We know that this individual will have the most extraordinary qualities. Indeed, the Health Select Committee has demonstrated that by the overwhelming vote that it gave him on his appointment. Therefore, any person of such calibre who is able to manage a quango with such an enormous budget must surely be able to manage a board of more than 11 people. That goes without saying.
	It is probably unhelpful for the Bill to specify precisely the number of people who will be appointed because circumstances will change. At different times it may be appropriate to have particular people or specialisms involved, but that will change over time. To lay down the numbers too specifically is probably a mistake. Indeed, I am not sure that 11 is a sensible number for the effectiveness of boards. It is too large for the most efficient and effective of boards but it is not quite large enough to bring together all the strands of opinion and expertise that you might wish to bring.
	My main reason for intervening was not to pick up on that point but to question a couple of the amendments, in particular Amendment 52C in the name of the noble Baroness, Lady Jolly. The amendment refers to the board,
	"including one member who is also the Chair of Healthwatch England".
	That is a misguided amendment. It is very important that the viewpoint of the patient is heard clearly by the NHS Commissioning Board, but it would be wrong to bind HealthWatch England into the collective decisions that will be taken by the NHS Commissioning Board. Had the amendment said something along the lines of, "The chair of HealthWatch England will be able to attend all meetings of the NHS Commissioning Board and to contribute to them fully" rather than talking about membership, it would have been much better.
	There is already a concern that HealthWatch England will not be seen as a properly independent organisation, partly because in the Bill it is framed as a committee of the CQC and also because the local healthwatch organisations will be wholly owned subsidiaries of local councils around the country and the money for them will not even be ring-fenced. Under those circumstances, there is a real problem about the reality of the independence of HealthWatch England. Further to put the chair of that body in the position of perhaps having collective responsibilities for NHS Commissioning Board decisions is potentially a serious mistake. I would like to see a position where the board has the chair of HealthWatch England as an adviser. His advice may or may not be accepted, but it will be on the record what advice has been given.
	I hesitate to oppose an amendment moved by my noble friend Lord Hunt of Kings Heath but the same applies to the Chief Medical Officer. He should be there to advise the board-and that advice should be recorded-rather than being a member of the board and therefore being part of that collective responsibility. In framing the structure of the NHS Commissioning Board, there needs to be clarity of thought. There are a number of areas of expertise and interests that ought to be reflected in board membership-those individuals should bring their expertise to the table-but they cannot be there as representatives of those particular interests because they will have to take collective responsibility for the decisions of the board. However, it is also important that you have explicitly there a number of people to give advice. That should certainly include the chair of HealthWatch England and the Chief Medical Officer.

The Archbishop of York: My Lords, I was not going to speak to these probing amendments, but as I have been gratuitously referred to twice it is prudent that I should speak.
	The noble Baroness referred to number 11. We should remember that Jesus had 12 disciples; the twelfth betrayed him and so there were eleven left. Then the disciples decided before Pentecost to choose Matthias, so they then had 12 again. They then ran into trouble once St Paul the Apostle came along and they had 13, but they did not know where to put him. Numbers are always dangerous.
	I am with the noble Baroness, Lady Murphy. We may need all kinds of characters on the board but it would be wrong to specify them in the Bill. If we do, then we will not have the kind of liberty and freedom to be creative and to enable the Secretary of State to promote a comprehensive health service and improve the quality of service. He needs that to help him promote the health service and then improve it. The board needs to consist of people who have the calibre to do that.
	I have sympathy with Amendment 54 but not in the precise form in which it is put. It states:
	"The Secretary of State must ensure that a majority of the non-executive members of the Board appointed under subsection (1)(b) have relevant experience".
	Those members should have relevant experience but as to whether they should be a majority, again, the discretion should be left to the Secretary of State and the board. If that is specified, they will all be there in big numbers but might end up not delivering or promoting whatever is required. Yes, the people appointed should clearly have relevant experience of either working in the NHS or serving on an NHS body-the NHS is not the same as Rover cars, Marks & Spencer or Tesco and you need people with relevant experience who are able to deliver properly-but I would go for the Secretary of State having people with relevant experience of working in the NHS or serving on a body without necessarily saying that they must be in the majority.
	As these are probing amendments, I shall be interested to hear what the Minister has to say about that.

Baroness Hussein-Ece: My Lords, I want to make a few brief comments on Amendments 50 and 52C. I listened to all of the arguments about the public health specialists being on the national board, and I think it is really important. If we are going to have, or aspire to, a national health service that is about prevention and improving health rather than just treating it, there needs to be somebody on the board who attends or has that specialism and brings in the local government perspective. I was involved nearly 10 years ago in appointing one of the early public health directors. It was a joint appointment between the PCT and the local authority that I represented. That person sat on the senior management board of both the local authority and the PCT and was able to bring that expertise to both of those boards. Importantly, in the local government setting, he was able to bring together the directorships of education, environment and social services and to ensure that, when we were trying to address issues such as teenage pregnancies-which is still a massive problem in this country-it was everyone's responsibility. It was not just over there; it was not just a health problem: it was a borough-wide problem. In terms of bringing that thinking on to the national stage-as other noble Lords have mentioned in this and other debates-local government has to be seen to be a key member if we are to aspire to improving the health of the population. Someone experienced in public health should have a very strong voice on the national, as well as the local, CCGs .
	I now turn to Amendment 52C in the name of my noble friend Lady Jolly, which aims to have as a board member someone who is also the chair of HealthWatch England. I support having the patient's voice heard at a national level. I listened very carefully to what the noble Lord, Lord Harris of Haringey, was saying: the important thing is to have the voice there. Quite often, with a group of 11 or however many it will be of the "great and the good", it is very important that we have somebody on that board who is going to represent the wider public as well-a lay person who can bring about some of the thinking that is going on locally around the country. The proposed chair of HealthWatch England might be bound in to some sort of collective decision-making which might sometimes make him or her quite unpopular with the other local HealthWatch organisations across the country. The most important thing we should be focusing on is that there is somebody on the board who has the authority, who can bring the voice of the patient and the public to this board.

Lord Beecham: My Lords, these are probing amendments: as the debate has shown, there is a great deal to probe. I hope that when the Minister replies, he will be able to answer some of the questions and give more details of the thinking that underlies the Bill as it stands, and how it might be carried out in practice.
	The body that we are talking about will have-as the noble Lord, Lord Harris has pointed out-an enormous budget and enormous responsibilities, both nationally and extending to localities. It will be responsible not just-just!-for commissioning general practice throughout the country, as the noble Lord, Lord Hunt reminded us, but also for a range of other services which will effectively be delivered locally. Yet in terms of the structure, composition and governance of the board, this Bill is about as skeletal as I imagine is the specimen that will greet first-year medical students at their first anatomy lecture. It needs flesh on the bones. There are a number of suggestions here; I have rather too many suggestions and I plead guilty to having advanced only some of them, but we clearly need a view about how the board will work and who will serve on it. I concur with the views of the noble Lord, Lord Harris, in relation to the appointment of the chair of HealthWatch England as proposed by the noble Baroness, Lady Jolly, as a member of the board. That person is likely to be conflicted: part of the job of HealthWatch will be to look at the operation of the board in an objective way. It may be that an attendance, as he suggests, would suffice.
	Although I put down the amendment about the Chief Medical Officer being a member of the board, I can see the logic of the suggestion of the noble Lord, Lord Harris, that the Chief Medical Officer should attend without necessarily being a member of the board. I am temperamentally averse to mixtures of executive and non-executive directors. In the local government sphere, I never felt very comfortable with chief officers voting alongside elected members, but I suppose that members of this board are not going to be elected: they are going to be selected. I therefore think that it is sensible to have the best advice possible available to the board in the way that the noble Lord, Lord Harris, has described.
	In terms of public health specialism, I think there needs to be a public health specialist-but not necessarily a serving public health specialist. I see the noble Earl, Lord Listowel, has tabled an amendment calling for the appointment of a former director of children's services. Without necessarily agreeing that that particular post should be designated, the concept of somebody with that experience-not necessarily being a serving member and therefore not conflicted-might well appeal. It is crucial-given that we are now going to have public health delivered in a very different way from what we had before, and basically rightly so, though in a complex structure that will involve the Secretary of State, the Commissioning Board and local government as well-that there should be a public health specialist of some kind serving on the board. I hope that the Minister may indicate a degree of sympathy with that.
	As to the total size, I am a bit ambivalent about that, too. It clearly needs to be a working board and therefore cannot be too large; it cannot possible reflect every conceivable interest. I agree with noble Lords who said perhaps it would be a mistake to prescribe the number in the legislation. That is a matter that could well be discussed later by the Secretary of State, no doubt having taken views and not least the views of the Health Select Committee in another place.
	I hope that we can make some progress tonight in identifying issues which the Government will look at sympathetically and bring back on Report. If they do not, then at least those of us who want to press points will have an opportunity of doing so.

Lord Greaves: My Lords, I have for most of this Committee so far been listening to and reading what people have said and have been astonished, as I always am, by the immense amount of expertise and distinction there is in this House. There are all the professionals, and there seem to be more former Health Ministers in this House than in any other place that could be gathered together. Most of the debate so far has been about high-level, national-level principles and structures, and we are now moving on to the area that I have been trying to get my mind around since I first obtained a copy of this extraordinarily huge Bill. That is the new structures that are being set up at all levels and how they are all going to work together.
	At Second Reading, I laid some claim for my party for some of the improvements that were made to this Bill after the pause in the House of Commons, but one thing that certainly happened to the Bill after that pause is that it became more complex as the number of different organisations and bodies became greater. The need for this House is to sort out how this new galaxy, or kaleidoscope, of new bodies within the health service are going to relate to each other and how it is going to work-I use the word "work" in a neutral sort of way-how it is going to happen in practice and how they are going to relate to those bodies which continue to exist, such as the hospital trusts, the PCTs, the strange clusters of PCTs that will stagger on for a certain amount of time and then disappear by some means that is not completely understood yet and, of course, local authorities and the whole of the voluntary and private sector involved in healthcare.
	I was interested to hear the comments of the noble Lord, Lord Harris of Haringey, on HealthWatch and its relationship at national level-and, indeed at local level-to these other bodies. That is an important issue which I hope we will go on to talk about before long. The Committee is beginning to bring expertise and experience from all sorts of personal levels to the debate, not just political stand-offs. That is what we should be doing. Personally, I support what the noble Lord said about the importance of HealthWatch being sufficiently independent and detached while also being able to be present at the table at all levels of bodies and at the national Commissioning Board, without necessarily being part of the collective responsibility for decisions. Noble Lords may want to think carefully about that principle. We will no doubt come back to it when we talk about HealthWatch specifically.
	There has also been discussion of the question of having a public health professional on the national Commissioning Board. This raises questions, which we will come to fairly soon when we talk about Clause 8, on the different ways in which the public health functions of the health service are to be dealt with compared with its clinical commissioning functions. In Clause 8, the public health functions of the health service are in future to be mainly divided between the Secretary of State, who will keep direct responsibility in this area, and local authorities, which will have enhanced responsibilities for public health and entirely new ones-though in many cases they regain functions lost in the 1974 reorganisation of local government.
	I have not yet got my mind round what the function and responsibility is of the national Commissioning Board in relation to public health. How will that work? Whether a specific public health professional should be required to be on the national Commissioning Board may depend on what the functions are of the NCB in relation to public health. It is impossible to put a clear dividing line between public health and clinical health issues. They overlap and are obviously incredibly interconnected. Nevertheless, how the administration will take place in future raises these questions. They need to be thought about carefully before a final decision is made on whether there should be public health representation on the national Commissioning Board.
	The particular amendment that I wanted to speak to before I started listening to the debate-which is always fatal: you should never do that but just stand up and say what you wanted to say-is Amendment 153ZA, presented to us by the noble Lord, Lord Hunt of Kings Heath, which goes under the beguiling title, "Duty to reduce bureaucracy". I could not help an ironic smile at that and could not help wondering why, if the noble Lord is so keen on that, he did not do a bit more to assist in it when he was a Health Minister. Perhaps that is an unkind thing to say-perhaps he did.

Lord Hunt of Kings Heath: Can I say how much I welcome the noble Lord, Lord Greaves, to our Committee? We have missed him. Now we have turned our attention to detail, his particular expertise comes to the fore.
	On bureaucracy, I have tabled this amendment because I have genuinely been a passionate fighter of bureaucracy. That is why sometimes as Ministers we have to intervene in the bureaucratic affairs of the health service. The noble Earl may find that he himself has to do so. My concern is that, partly because of the listening pause, there is now a plethora of organisations to be established. Apart from clinical commissioning groups, we have commissioning support units-about which we have heard very little but apparently will be there-as well as the senates, the health and well-being boards, the clinical pathways and the national Commissioning Board. The regulators are likely to be given more power in the future: Monitor is being given more powers and, post Francis, there will probably be changes to the CQC and other regulatory matters. The risk is that, far from this being a streamlined process, it will be a very complex and bureaucratic one. I seek here merely to help the Government deliver their aims by encouraging them to restrain the cost of the whole exercise.

Lord Greaves: I was of course teasing the noble Lord in as pleasant a way that I could. This is another instance where Hansard ought to have a few smileys liberally littered round the text. The noble Lord made the same point, at slightly greater length, that I made when I referred to the kaleidoscope of bodies that we now have. An important job of this Committee is to sort out the relationship between all these different bodies before they are finally set up. We have got to do that absolutely vital job.
	Subsection (2) of the noble Lord's proposed new section "Duty to reduce bureaucracy" says,
	"For that purpose the Board must exercise its functions ... so as to ensure that at no time there exists more clinical commissioning groups than there were primary care trusts on 1 April 2011".
	That is a slightly different point, hitched on to his bureaucracy point. This is a vital question. Again, this will not appear in the Bill-it will not say that there will be X number of clinical commissioning groups-but, in general terms, we need to have clear in our minds when the Bill leaves the House how many clinical commissioning groups there will be and of what sort of size. This has evolved with discussion over the legislation. When the first proposals came out-when they were called GP commissioning groups because that is what they were-there was a feeling among many people throughout the country, the health service and among politicians that they might be quite small, or even that large GP practices might try and do it on their own. A lot of people were alarmed by this because they thought it would not be very efficient and it would not work. How on earth do you commission the kind of facilities which have to be provided, whether it is a local health centre or specialist clinical services, on a sufficient scale? The more people thought about it, the more it seemed that these groups had to be larger than just a large GP practice or group of GP practices in a smallish town.
	The Government then encouraged GPs in particular areas to get together and co-operate to set up early-stage shadow commissioning groups. This happened and the Government issued a statement saying that a high proportion of the country-I forget what, but perhaps 70 or 80 per cent-was covered by these voluntary, shadow groups. These GPs quite rightly wanted to make things work in their area, whatever they thought of the legislation and changes. In my part of the world, it tended to come down to one commissioning group per second-tier or lower-tier district council area, in places like Burnley, Hyndburn and Pendle. Now, apparently because of pressure from above, people are talking very strongly about having-or having to have-a commissioning group on the same boundaries as the existing primary care trust. This would not be the cluster of trusts that is at the county level but at a sub-county level.
	So in effect people are looking at the groups and saying, "What will be the difference?" What will be different will be the functions and the direct control of community services, which effectively has gone already to the hospital trusts. As for commissioning, it will be effectively the same body, probably in the same premises, controlled by different people. We need to understand this regardless of whether it is necessary to reduce bureaucracy or whatever, which is secondary, in a sense. Before we leave the question of the commissioning groups, which we will be talking about in great detail, we in this House need to understand the Government's thinking about the future likely site of these groups.

Lord Hunt of Kings Heath: I am grateful to the noble Lord for giving way again. I think it is a very interesting point about the size of clinical commissioning groups. My amendment was simply a probe to get a debate on this. Is there not a tension here? In order to get CCGs dealing with strategic issues, they have to be pretty large and cover a large population, but, in order to get the interest of GPs, they need to be smaller because the GPs need to feel involved. In essence, there is a tension there. The approach of the previous Government of taking primary care trusts and encouraging more practice-based commissioning may well have proved to be a better approach. The risk with CCGs at the moment is that, when they emerge with a board, they will be so removed from the individual GP that the very purpose of setting them up in the first place, which of course was about controlling demand through GPs, will lose that essential aim.

Lord Greaves: There is a great deal of truth in what the noble Lord says. Looking at this from afar, I think that the Government have had to struggle with this tension. In order for the bodies to be serious commissioning bodies, commissioning not just for their patients individually or collectively but for the health needs of their area, they have to be sufficiently large. What will happen is that the GPs who sit on these new commissioning groups almost certainly will represent the GPs in the whole of that area, and they will have to be appointed by some democratic process representing the whole area-perhaps one from each area. I do not know how they will do it but that will have to happen at a local, practical level.
	In my view, one thing that has bedevilled this debate is that the word "commissioning" has been used in two quite separate senses. One has been the idea of a GP commissioning services for his particular-

Lord Warner: I am sorry to interrupt the noble Lord's flow, but I would like to press him a little further to give us some clue as to his thinking on this. My noble friend Lord Hunt gave us a snippet of history, but there is quite a lot more. We have been through a process where we have come down since 2002 from 300 PCTs to 50 or so PCT clusters. We have been on that journey because we found it extremely difficult to commission services effectively when there are very large numbers of PCTs covering small geographical and population areas. There is simply not the expertise to do that. Could he give the House some clue about where he thinks this is all going to end up? At the moment, in terms of starters for 10, we have about 250 of these clinical commissioning groups. I think it would be helpful to know where the members of his party and others who have argued for this stand on where the journey may end.

Lord Greaves: I am extremely flattered that the noble Lord, Lord Warner, thinks that I have the slightest idea where it is going to end up. I am doing exactly what the noble Lord, Lord Warner, and other noble Lords are doing-trying to get the Minister to give us some idea of that. We will be interested to see whether he gives that. Over the political lifetime of this subject, we have had constant changes. We started with bigger area health authorities and smaller district health authorities, going down to district level, and then going back to the area level, with the regional level having a greater or lesser influence. The fact is that this is a fundamental administrative difficulty-not a philosophical difficulty-for an organisation like the health service.
	Everybody tends to think that what they have at the moment is not perfect and therefore they try to change it. Because there are only a limited number of options available, it goes backwards and forwards, from local to less local back to local again. If the noble Lord thinks that I know what is going to happen, I am afraid that I do not have the slightest idea. It seems to me that we need a clear idea of what this Bill is going to result in when it leaves this House and we need to understand how it is going to work. In a sense, the details of that matter less than the workability of it.
	The point that I was making about "commissioning" being used with two different meanings is that it is used for a particular GP practice commissioning services for the people on its list-

Lord Hunt of Kings Heath: From what the noble Lord said, why on earth did we not continue with PCTs and give them a kick up the backside to allow GP surgeries to commission more locally as well? Why have we gone through this?

Lord Greaves: I am not quite sure why the noble Lord is asking me that question. He is tempting me to make provocative statements in relation to the coalition Government of which my party is a member. I think that it is an open question and the answer can remain open. I am not in the mood to make provocative statements today. I might be tomorrow, and the noble Lord can come back to me then.
	The point that I am trying to make before I finish, if the Labour Benches will not interrupt me just one more time-

The Archbishop of York: The Benches opposite are probably provoking you into some kind of statement because of your earlier comment that you were reputed for having influenced the Bill during the pause. Given that influence, why did you not go back to what was working?

Lord Greaves: It is our view that the original proposals were not working at all, and the proposals that we have now are better than the original ones. That does not mean to say that they are perfect, and it is the job of the House of Lords to check that the imperfections in them are removed before the Bill leaves your Lordships' House.
	The point that I was trying to make, which I will finally make once more, is that there is a real difference between the two meanings of "commissioning". If you are a GP, you can commission services from an existing, static landscape or system of provision for your patients. However, commissioning services on a wider scale, commissioning the very landscape of services and the series of organisations that exist, whether it is deciding to put more money overall on a wide scale into one area of medicine and pulling back on others or just keeping the others going as they are, or whether it is financing capital projects-where to build new hospitals, new health centres or whatever it is-is very different indeed. You need bodies on a larger scale to do that. The idea that practices on their own or small groups of practices could commission that kind of undertaking on a wider scale is nonsense. You cannot rely on the market to provide them all because that will produce chaos and a lack of provision in many areas. That is why the original proposal for GP commissioning groups, which were to be quite small, simply would not have delivered at that level. The original proposals did not indicate in any way how that wider capital commissioning would take place.

Earl Howe: My Lords, this has been an excellent debate on a set of important issues, and I am glad to count my noble friend Lord Greaves as one of my staunchest supporters.
	The NHS Commissioning Board is one of the key elements of our vision of a modernised NHS-a highly professional organisation, focused on q quality and able to support clinical commissioning groups in delivering the best care possible to patients. I completely accept that these amendments were proposed with the best of intentions, to strengthen the way in which care is commissioned. However, in setting out why the Bill is drafted as it is, I hope that I can explain to your Lordships why I cannot accept them.
	It will be key to the effectiveness of the board to ensure that it obtains sufficient advice and input from clinicians, public health experts, other professionals and those with relevant experience of the NHS-patients and the public-and that it has effective working relationships and arrangements with local authority government. We have stated our intention that there should be clinical and professional leadership on the board, but in terms of the legislative framework for the board it is an important principle to maintain that it should have autonomy of decision-making on matters such as its own membership and its structures and procedures, as far as possible, to determine how best to exercise its functions. This would include, for example, whether it has a vice-chair or a senior independent director, as Amendment 52B suggests.
	One thing is absolutely clear. Members of the board will, in practice, need to have a range of skills, knowledge and experience appropriate to the issues faced by the board. Ensuring the right balance of non-executive members from a variety of backgrounds is key to achieving a successful board. But if the majority of non-executives were required to have a particular background, such as NHS experience, as suggested in Amendment 54, that might create an unbalanced board and effectively disqualify potential candidates from the private and voluntary sectors. I agreed with the most reverend Primate in what he said here. It is worth remembering that the board and its members will be expected to follow the seven principles of public life-the Nolan principles-one of which will mean that it must appoint a,
	"well-informed choice of individuals who through their abilities, experience and qualities match the need of the public body in question".
	That sums it up very well.
	A number of noble Lords made the point that if we require the inclusion of doctors and nurses or a public health specialist as put forward in Amendments 50, 52D, 54B and 56, what about representation on the board of dentists, pharmacists and allied health professionals? The list could go on. It would simply not be possible to accommodate all interests in the board's membership adequately, and we would surely invite valid criticisms that one group is being prioritised over another. Nor would this be desirable from a Government's point of view, given that the primary purpose of the members of the board is to hold the organisation to account. Nor, in my very firm view, would it be appropriate for a senior member of another organisation with a different purpose or remit, such as the chair of HealthWatch England, or indeed the Chief Medical Officer, to have a seat on the board, as suggested in Amendments 52C and 54A respectively. That could lead to a potential conflict of interest and confuse accountability. I agreed with the noble Lord, Lord Harris, on that point-although he is not in his place.
	Of course, in practice, the board must have the freedom to determine how these varied and legitimate interests are best involved and represented in its work. The noble Baroness, Lady Murphy, was quite right-the board will want advice and expertise readily available to it-but that is a different issue from board membership. It is worth bearing in mind that the board will have the freedom to appoint committees and sub-committees as it considers appropriate, and this may prove useful to the board to bring in interested parties on specific issues.
	A number of noble Lords asked about public health expertise. We are coming on to debate clinical senates, but one main reason for establishing them is to bring in this wider range of expertise in a way that would provide practical benefit. This would absolutely include public health expertise. We amended the duty to obtain advice to make this explicit. New Section 13J inserted by Clause 20 makes it absolutely clear that the board must obtain advice from those with professional expertise in,
	"the protection or improvement of public health".
	There will be an interrelationship between the board and HealthWatch. The board must inform the body in writing of its response, or proposed response, to its advice; it must also have regard to the views, reports and recommendations of local HealthWatch.
	My noble friend Lady Cumberlege asked about the size and membership of the board. The requirements in the Bill are that there is a minimum of seven members; the Secretary of State must appoint a chair and at least five other non-executives, so that is a minimum of six non-executive members. The non-executives must appoint a chief executive, who must be a member of the board. That is to say, there must be at least one executive member. Beyond that, they may appoint other executive members as long as the total of non-executives is always more than the total number of executives. The final decision on the number of other executive posts and the nature of their roles will need to be agreed with the chair and non-executive members, but it is envisaged that the other executive members besides the chief executive will include a nursing and a medical director, a director of finance, of performance and operations and of commissioning development.
	All departments are required to ensure that appointments are open, transparent and made on merit. The Commissioner for Public Appointments regulates the processes by which Ministers make appointments to the boards of certain public bodies in England and Wales, and this will continue to be the case. It is not government policy to offer confirmation or affirmation hearings for public appointments, as Amendment 52A, tabled by the noble Lord, Lord Hunt, would require. These are ministerial appointments to make. The Cabinet Office maintains a list of posts that are subject to pre-appointment hearings by a House Select Committee. Ministers would consider the committee's views, but such hearings are not binding and do not represent a power of veto. Your Lordships will be aware that we followed this process in the recent appointment of Professor Malcolm Grant as the chair of the NHS Commissioning Board.

Lord Hunt of Kings Heath: I am grateful to the noble Earl for what he said, but did he pick up my point that the Government set the precedent in relation to legislation with regard to the Office for Budget Responsibility? The Government have moved on, and I am sure that they did it because of the importance of that body. My argument is that the National Commissioning Board will be such a responsible body that there might well be an advantage in giving the Health Select Committee rather more leverage on it.

Earl Howe: My understanding is that we are following the normal procedure. There is a list of appointments that are subject to Select Committee scrutiny. Departments are consulted over the list. It is our intention that the role of the chair will be included in that-and that is exactly the same situation that applied under the previous Government. The Office for Budget Responsibility is an exceptional body in this respect, given its role in providing both government and Parliament with essential, impartial information, necessary for both bodies to be able to fulfil their responsibilities. Although I will reflect on the noble Lord's comments, I do not know that there is the parallel that he seeks to make there.
	Amendment 55 would remove the requirement from the Secretary of State to approve the appointment of a chief executive of the board. This requirement is included for the important reason that the chief executive of the board will be the accounting officer for the commissioning budget, so it is entirely appropriate that the Secretary of State should approve his or her appointment.

Lord Warner: Can I press the noble Earl a little further on that? If a chairman has been appointed for this body who has a level of experience to enable him or her to function at that level, then requiring the Secretary of State to approve the appointment of the chief executive seems to throw into doubt whether the Government have confidence in that chairman running that kind of body-they need to be able to appoint an accountable officer as their chief executive. I find this a pretty considerable vote of no confidence in the kind of people who are being appointed as chairmen.

Earl Howe: Not at all, my Lords. Of course we have confidence in the chairman. However, it is a little strange to hear from the noble Lord that he suddenlythinks the Secretary of State should not be involved in an area where he has a legitimate interest to make sure, on behalf of the taxpayer and indeed patients, that we have somebody who is capable of fulfilling the role of accounting officer. This is an important role for the Secretary of State to have.
	Turning now to Amendments 57, 153ZA and 153B, let me assure the Committee, and especially the noble Lord, Lord Hunt, that we want to reduce the amount of NHS funding spent on back-office bureaucracy. That is why have made a commitment to reduce administration costs across the health system by one-third in real terms, saving £1.5 billion annually by 2014-15. All that money will be put back into patient care.
	Clause 21 provides powers for the Secretary of State to impose certain limits on the overall expenditure and use of resources by the board and clinical commissioning groups, including in relation to administrative matters defined through parliamentary regulations, for the first time. The board has the power to set similar limits for individual CCGs. I see no reason to change this to a duty to do so, as Amendment 153B suggests. As the board will itself be responsible for overall administrative spending, I am sure it will want to use this power carefully. Within those limits, it should be for the board to determine how best to use the resources available to it, and to decide on its own structures and ways of working, and the number of staff that it needs to perform its functions effectively. It is not appropriate to set a staffing cap on an arm's-length body.
	How big will the board be? In a document called Developing the NHS Commissioning Board, Sir David Nicholson, chief executive-designate of the board, estimated that the board was likely to have 3,500 staff, carrying out the functions currently exercised by around 8,000 staff in the Department of Health, strategic health authorities, PCTs and a number of arm's-length bodies that are being abolished, along with its own new functions. It will deliver these in a much more streamlined way.
	Likewise, setting an arbitrary cap in the Bill on the number of clinical commissioning groups or on their expenditure on administration in comparison to PCTs is not, in our view, an appropriate means of controlling administrative costs. CCGs will be different from PCTs. They put local clinicians in charge and align clinical decisions with the financial and quality consequences. It is a little unfair of the noble Lord, Lord Hunt, to say that we are creating a complicated and bureaucratic system, and citing clinical senates and networks and health and well-being boards. Clinical senates and networks are not new organisations in their own right: they will be hosted by the board. Clinical networks already exist. Health and well-being boards are also not separate statutory organisations: they will be hosted by local authorities. We are abolishing a whole raft of bodies under this Bill, as I have said on previous occasions. It is important to bear that in mind.
	I appreciate the concerns underlying Amendments 58 and 59. It is important that there should be transparency in all the workings of the board. This is why Schedule 5 to the Bill was amended in another place to include the board in paragraph 7 as a body to which the duty in Section 1 of the Public Bodies (Admission to Meetings) Act 1960 applies. This would include any annual meeting that the board may decide to hold. I say "may decide" because the Bill is clear, in new paragraph 12 in Schedule 1, that:
	"The Board may regulate its own procedure".
	This would also apply to determining when it is quorate.
	However, the Bill does include clear procedures around the publication of the board's annual accounts and annual reports, to ensure transparency. The board must send its annual accounts to the Secretary of State and the Comptroller and Auditor-General. The latter must examine, certify and report on the accounts and then lay copies of the accounts and the report before Parliament. The Comptroller and Auditor-General is responsible for the audit of the accounts of all arm's-length bodies. The board must publish an annual report and lay it before Parliament. The Secretary of State must then write to the board, providing an assessment of the board's performance of its functions, publish the letter and lay it before Parliament. That gives an indication that there will be maximum transparency here.
	Turning to Amendments 145A, 146A, 147ZA and 147C, I am afraid that I do not agree that it would be worth while to add the unusual burden of an explicit duty of consulting on a draft business plan. The board is already required in new Section 13P(2)(a) to involve and consult the public in planning its commissioning arrangements. Under a duty in new Section 13J, it is required to obtain appropriate advice to enable it effectively to discharge its functions, including the planning of how it will exercise its functions.
	I hope I can reassure noble Lords that Amendments 147A and 147B are also not necessary. First, the duty to produce a business plan already provides for transparency by obliging the board to publish its plan. Secondly, while the Bill requires that the board's annual report and annual accounts are laid before Parliament, that is part of specific processes for scrutiny of the board's performance against the objectives it was set and the outcomes it has achieved. It is right and proper that the board should be held to account in such a way. Another clear recommendation by the NHS Future Forum was that the autonomy of the board needs to be respected. With this in mind, although it is right that the board should be required to produce a plan and for that plan to be published for all-including Parliament-to see, I am not convinced that it would be appropriate to have parliamentary scrutiny of the board's plans or draft plans. The Bill places certain functions on the board, and it should be for the board to determine how it will seek to exercise these.
	With regard to the questions asked by my noble friend Lord Greaves concerning the size of clinical commissioning groups, I respectfully suggest to him that we defer them to a later group of amendments, where this issue will come up and I shall be able to talk more about it. For now, I hope that the noble Lords are sufficiently reassured to be able to withdraw the amendment.

Lord Greaves: Before the noble Earl sits down, the question I asked about the specific role of the national Commissioning Board in relation to public health is one that he did not address. Can he tell us when he might address it?

Earl Howe: I apologise to my noble friend. The national Commissioning Board will, we envisage, be tasked with commissioning a number of public health functions by Public Health England. There will be a close relationship between Public Health England and the board. Much of the work of the board will straddle both public health and the provision of NHS services. There will be an intimate symbiosis between the two bodies.

Lord Warner: My Lords, on Amendment 50, which I seem to have moved quite a long time ago, I will consider the noble Earl's remarks. I am grateful to noble Lords who spoke in support of Amendment 50. Public health is a rather special case and I would want to reflect, in a later debate, on the public health amendments. In the mean time, I beg leave to withdraw the amendment.
	Amendment 50 withdrawn.
	House resumed. Committee to begin again not before 8.39 pm.

Agriculture: Egg Industry
	 — 
	Question for Short Debate

The Earl of Shrewsbury: To ask Her Majesty's Government what is their assessment of the impact Council Directive 1999/74/EC will have on the competitiveness of the United Kingdom egg industry from 1 January 2012.

The Earl of Shrewsbury: My Lords, I am most grateful to the House for providing me with the opportunity to raise this matter, which is of very considerable importance to the future well-being of the British egg industry. I declare an interest, as my younger son is a producer of free-range eggs in Lincolnshire and contracted to Britain's largest producer of eggs, Noble Foods. As my noble friend the Minister will be fully aware, the welfare of laying hens directive, which is the subject of this Question, comes into full force on 1 January 2012. The directive prohibits the use of conventional battery cages and the marketing of eggs from hens housed in such cages. The new cages, known as enriched colony cages, will provide a more animal welfare-acceptable environment. Yet again, Great Britain is leading the field in agricultural animal welfare but such action comes at considerable cost to this sector of agriculture.
	The British Egg Industry Council estimates that the industry has, to date, invested some £400 million in the new cage systems and that this country will be fully compliant by 1 January. This has been a truly massive change to the industry. Those producers who have not been in a position to upgrade their systems to the enriched colony systems have gone out of business. Others who have been in a position to make the change have invested heavily in the new systems; such investment has to be serviced and the capital repaid. However, while Britain will be fully compliant there is a very real concern within the industry that producers in some other EU member states will not be-indeed, some might never be.
	In recent research conducted on behalf of the British Egg Industry Council, it was found that UK retailers, caterers, manufacturers, processors and producers have for some time been working together to secure the supply of eggs and implement traceability systems to ensure full compliance with legislation. As a result, it is anticipated that the vast majority of shell eggs and all Lion Mark eggs produced in the UK will comply, and that all major retailers will sell own brand shell eggs with the Lion mark. However, further evidence suggests that the main difficulty will be in ensuring that imported shell or processed egg used in manufacturing or catering products will be compliant. This will be particularly so where eggs or egg products are imported directly from those member states where doubts have been raised about the producer's ability to implement the legislation, but also from member states which have taken in eggs to process from non-compliant producers in other member states.
	The matter is further complicated by the fact that in member states where there will be non-compliance there are farms with both conventional cages and enriched colony cage systems, often on the same site, thus making policing and traceability extremely difficult. The fact is that we in the UK are not self-sufficient in our supply of eggs. I believe that we produce 85 per cent of the eggs that we need. Egg products are also included in this, and therefore we need to import.
	When this directive was first discussed, the egg industry thought that it was not good news but following comments made recently by Commissioner Dalli, the industry is far more worried for the future. The industry is not afraid of competition from legal imported eggs but is extremely concerned that if the directive is not uniformly implemented across the EU from 1 January 2012-and it is as clear as crystal that it will not be-it will be at a serious and unfair disadvantage because of the risk of non-compliant eggs and egg products with considerably lower associated costs being imported. All the industry wants is to be treated fairly and to be able to compete on a level playing field. Can my noble friend the Minister say whether, following 1 January 2012, first, anyone in the UK using eggs or egg products from illegal cage systems will be breaking the law and, secondly, what action Her Majesty's Government envisage taking to ensure that only eggs and egg products from compliant cage systems will be imported into the UK following that date?
	The British egg industry is highly successful and very efficient. It has improved in leaps and bounds since the introduction of the Lion brand as a measure of quality. Consumers have confidence in the product and the poultry sector is one of the great successes of British agriculture. Should Her Majesty's Government fail to act in the interests of the UK egg industry to stop the import of cheap non-compliant eggs and egg products, the British egg industry will be in very real danger of following down the path of the pig sector in the UK. Since 1999, the national pig herd has declined by 40 per cent through the import of cheap pig meat, produced in inferior systems and with far lower animal welfare standards.

Lord Plumb: My Lords, I declare my interest as a farmer-not as an egg producer, but one who recognises the egg industry as one of the most efficient sectors of British agriculture. I congratulate my noble friend Lord Shrewsbury on securing this short debate on an issue that is pertinent to today's problems and that affects producers and all who are concerned and involved in the industry. As my noble friend said, the pig industry went this way some time ago, when welfare standards were improving in this country; not so in some other countries from where we are still importing pig meat. This relates to the Council directive, agreed in 1999, that battery cages should be phased out and welfare standards improved. I remember it vividly because it was my last year serving in the European Parliament. I well remember the debates that we had then, but it went through and here we have it. It should now be fully implemented on 1 January.
	The estimated cost to the industry of £400 million to convert from battery cages to what are called enriched colony cages, which afford the hen 50 per cent more space than in a battery, is something that we must obviously take note of. For a producer who has a medium-size unit of 100,000 birds, the cost of erecting a new unit will be in excess of £2 million. In addition to people who have been in that situation and are converting, we are seeing free-range producers, and those who are also involved in free range from battery hens that they had before, being involved heavily in the preparation for the 1 January deadline. This follows that European directive on the welfare of laying hens, which prohibits the use of battery cages from 1 January. We should be proud of a business whose people have responded to the demands of consumers concerned with welfare standards. I understand that the majority of birds are going into the enriched cages by the deadline. In this country, under the egg industry's assurance scheme, producers have agreed that they will meet the deadline by 2012.
	As my noble friend said, the UK is not self-sufficient in eggs, with some 15 per cent being imported. We produce 9 billion eggs in this country every year, with 10,000 people being involved directly in the egg industry and 13,000 indirectly. I hope that my noble friend the Minister can satisfy British producers that the Government will not agree to eggs being produced in lower welfare battery cages, which can be imported into the UK, undermining the market and therefore distorting prices. From the figures submitted by the Commission, after requesting all member states to submit figures on the number of hens in cages, it would appear that there is still a significant number of hens in conventional cages, particularly in major countries such as Spain, Portugal, France and Italy. The single market surely has to be based on equal standards on trade and welfare grounds and there has been ample room and time for this to develop since 1999.
	British consumers can be satisfied that the 31 million eggs consumed each day are a key source of food and nutrition. The salmonella scare of the 1980s sparked panic in the country and among producers but, in a test of 28,000 British eggs in 2004 the Food Standards Agency found no salmonella; tests in 2008, 2009 and 2010 showed further improvement. There is continued satisfaction, therefore, in the quality of the product. The progress made in the United Kingdom is a great success story which must not be undermined by cheaper imports produced in countries with lower welfare standards.

Lord Greaves: My Lords, I too congratulate the noble Earl, Lord Shrewsbury, on bringing this matter to the attention of the House and look forward to the Minister's reply. As always, I enjoyed listening to my noble friend Lord Plumb and his robust representation of British agriculture, which, as he rightly says, is in the forefront of egg production.
	The changes we debate originate from a welfare of laying hens directive 1999/74/EC, which comes into full force on 1 January 2012. From that date it will be illegal to use what most people would call battery cages but, in slightly obscure Euro-speak, are now called non-enriched cage systems of 550 square centimetres-a great deal less than it sounds. The minimum requirement will be an enriched cage system with more living space per hen-at least 750 square centimetres and a nest, perching space, litter to allow pecking and scratching, and unrestricted access to a feed trough. Many of us would still find this a small cage space in which to live but it is nevertheless a very significant improvement. That is the positive side and a good example of why we need to be in the European Union and why the European Union needs to legislate on such matters. Without legislation across Europe it would be very difficult to bring in this kind of law because of the competitive pressures which, in this transitional period, we are concerned about.
	This is reported as being the first piece of EU legislation to ban a specific method of food production on animal welfare grounds. I do not know if this is true but there will be and there should be more. The problem with this, to be frank, is that the implementation of it by the European Commission has been botched. The House of Commons Environment, Food and Rural Affairs Committee issued an excellent report on this matter on 2 September. The press release said:
	"The European Commission is sleepwalking into a potential commercial disaster over animal welfare regulations that could result in unfair competition for UK egg producers".
	As previous speakers have said, that is the nub of the problem. It is being suggested by trade sources that perhaps one-third of European egg production on that date will not comply and will be illegal. It is suggested that half of the 300 million laying hens currently producing eggs in conventional cages in the 25 European countries do not at the moment comply and will have to change. It is a difficult position and the Commission has proposed a transitional period covering half a year but says this must be voluntary. It is absolutely clear there will be a problem, at least for a substantial part of the next year and perhaps longer. It is all a very worrying precedent for the future of animal welfare legislation in the European Union. The legislation may be excellent but if it cannot be introduced in a competent way then it will produce this kind of problem.
	Can the Government of this country ban the import of eggs, processed eggs or products including eggs which do not comply? If they cannot, what action can be taken? The Environment, Food and Rural Affairs Committee suggested in its recommendation 13,
	"that the obstacles to establishing a trade ban that encompassed all products that contained egg derived ingredients produced in non-compliant cages may well be insurmountable".
	It therefore recommended that:
	"Defra investigate establishing a voluntary approach under which retailers and food manufacturers",
	in this country,
	"would undertake stringent traceability tests",
	-and all egg producers throughout the European Union are supposed to be registered and declare what system of egg production they are using-
	"to ensure that they are not responsible for bringing products containing non-compliant egg products into the UK. We further recommend that Defra publish a list of those retailers and food manufacturers that have signed up to the voluntary approach".
	I suppose that is the "naming and praising" approach; people not on the list can be shamed. Recommendation 16 was that Defra should,
	"press the Commission to bolster the powers and resources of the Food and Veterinary Office".
	Is it doing that? It further recommends that after 1 January the Government should not purchase any eggs that come from non-compliant sources. Is that government policy? Will that instruction go out and will the Government make whatever effort they can to make sure that the whole of the public sector in this country follows such recommendations?

Earl Cathcart: My Lords, I congratulate my noble friend on the timing of this debate. With EU civil servants failing to reach agreement on 28 October, this issue is to be discussed today and tomorrow at the meeting of the EU Ministers. Like my noble friend, my son has a free-range egg contract through Noble Foods, which takes place on my farm. With Brussels failing to reach agreement, UK egg producers fear that Britain will be subjected to a flood of cheap imports from countries breaking the law by still using illegal cages. While Commissioner Dalli says he will not postpone the introduction of this new legislation, he will not permit the destruction of illegal eggs. He has come up with a number of proposals to soften the blow for those countries which, unlike Britain, have failed to comply with the law. In effect, he will be postponing the introduction of the legislation.
	It is important to appreciate the magnitude of the problem. There are expected to be 80 million illegal laying hens from 1 January 2012, laying between 20 and 25 billion illegal eggs a year. Italy will have a staggering 25 million illegal hens, France 9 million, Poland 17 million and Spain 20 million, which is about half its total laying hen population.
	Let us look at some of Commissioner Dalli's proposals. First, he wants on-farm inspections followed by legal proceedings. Call me cynical, but I cannot see the Italian or Spanish inspectors bothering. They have not in the past, so why now? Secondly, Dalli proposes that all illegal first-quality eggs must be processed into liquid or powder. This would be totally impractical. There is neither the processing capacity nor the market demand for the processing of nearly 25 billion illegal eggs a year. In Spain, currently about 15 per cent of eggs go into processing. How on earth is its processing going to be increased to 50 per cent of its total egg production within the next two months? It is just not going to happen. Thirdly, Dalli proposes that no more pullets are to be housed in illegal cages from 1 January. This is impractical; for example, many of the pullets to replace the 20 million Spanish hens in illegal cages from 1 January have already been reared, as they will be delivered when they are already 16 weeks old. Where else can all these birds go if not into illegal cages? I cannot see the Spanish destroying them.
	Fourthly, Dalli proposes a final cut-off date of 31 July to comply. Unfortunately this date makes no sense, as the life cycle for laying hens is 14 months, not seven. Even if there was the will to comply with the directive and the money was available to finance the required changes, this timescale is not achievable. It takes at least six months to refit or build a poultry house and there is not the capacity or money in the EU to erect housing for 80 million laying hens in the next nine months. It is completely unrealistic. Fifthly, Dalli proposes that if illegal cages are to be used, the current stocking requirement of 550 square centimetres per hen must increase to 750 square centimetres to give each hen more room. For most illegal cages, this would mean removing two hens per cage. Can you imagine this really happening-that the foreign farmer will slaughter his surplus hens, hens that have been making him a perfectly good profit? I do not think so.
	Dalli plans that these and other proposals will be implemented under a gentleman's agreement. He does not propose any new legislation or regulations to enforce them. Can you see it? Once Dalli leaves the door ajar, the illegal egg producers will storm through it, entrenching large-scale illegal production in certain EU states and creating a deeply uneven playing field. UK producers would be at a permanent competitive disadvantage just like in the pig industry. Frankly, I do not believe that any gentleman's agreement would be worth the paper it is written on.
	Where now? What do we want the British Government to do? First, the concerns felt by the British egg industry need to be conveyed to Brussels as a matter of urgency: that Dalli's proposals are unworkable and totally unsatisfactory as far as UK producers are concerned; that Britain will not import any illegal eggs, egg products or prepared food containing egg products after 1 January; and that Britain, along with other compliant countries, should insist that no illegal eggs or egg products can be exported from the country of origin, even for processing.
	There is a chink of good news. Last Monday my honourable friend Jim Paice, speaking at the Egg and Poultry Industry Conference, confirmed that anyone in the UK using eggs or egg products from illegal cages would be breaking the law. He went further by saying that it needed to be made clear to owners of branded food products that the law applies to their ingredients. He added that any company using eggs produced from illegal cages from 1 January would be breaking both the letter and the spirit of the law. Of course, this is most welcome, but what plans does Defra have to ensure that known importers of eggs or egg products from the continent are alerted to the change in the law-that the importation of eggs and egg products produced from banned cages from 1 January will be illegal? Will they be fined or threatened with closure if they persist? Treating like with like, if a UK egg producer still used illegal cages after 1 January he would be heavily fined and his business shut down. The same two questions apply to the owners of branded food products. Will the Minister alert them and will they be penalised if they break the law?
	We joined the Common Market in 1973 thinking we would get a level playing field for trade. After 38 years, is it not about time we got one?

Lord Lexden: My Lords, I am a newcomer to the important matters highlighted in this debate, for which we are indebted to the noble Earl, Lord Shrewsbury, who introduced it-the first of two Earls to speak in this debate, which lends it a splendid distinction.
	I wish to speak briefly about the effect this directive will have on the egg industry in Northern Ireland, a part of our country in whose well-being-all aspects of it-I am always deeply interested, as I have pointed out before in your Lordships' House. I do not believe that the existence of a devolved Assembly should preclude the discussion of Northern Ireland issues in this House, particularly where a wider UK dimension exists, as it does with this issue.
	It is estimated by the Ulster Farmers' Union, a long established and highly regarded voice of rural interests, that the Northern Irish egg industry is worth some £50 million a year to the Province's economy. When this directive was published in 1999, many of the problems foreseen then by the UFU and their colleagues in other parts of the country have still not been resolved, although the European Union has had 12 years in which to put in place measures to ensure that compliance does not entail a competitive disadvantage for our farmers, as other noble Lords have already stressed. They have also stressed that fairness-a level playing field, in today's well loved jargon-for poultry farmers is absolutely essential, given that in the United Kingdom in particular this industry historically has not enjoyed direct government support.
	My friends in the UFU estimated in 1999 that 1.8 million birds in Northern Ireland would need to be moved to the new "enhanced colony cages", at a cost of around £10 a bird. The average cost of conversion to the Northern Irish poultry farmer has been estimated at £300,000-or more, should they decide to convert to free-range production rather than the enhanced colony cage systems. Farmers south of the border in the Republic of Ireland have been eligible for financial help amounting to roughly 40 per cent of the cost per bird of conversion. Despite helpful discussions with United Kingdom Ministers, no similar assistance has been forthcoming to help farmers in Northern Ireland, who compete in the same geographical market.
	Those more familiar than me with the farm modernisation scheme will know it to be a heavily oversubscribed fund, with no specific remit to help the poultry sector in particular, and will be unsurprised to hear that it has been of little help to the Ulster farmer looking to convert. The £300,000 cost is coming in the form of bank loans which will require repayment in the harsh economic circumstances in which we find ourselves, and amid a price war among the major supermarkets, which is preventing producers from raising the prices of their product. Several UFU members considered the costs too great at the outset, and ceased production. Small-scale, family-run farms, vital to Ulster's important rural economy, have been replaced by major industrial producers, and others are at risk.
	It is also worth bearing in mind that while the EU itself has had more than a decade to deal with the problems this directive might cause, farmers themselves have enjoyed no such luxury. A report due in 2005, but not published until January 2008, set the standards for these enriched colony cages, and farmers in Ulster prudently waited-they are extremely prudent, for the most part, in Ulster-until they could read this report before undertaking major financial risks. This was an excellent decision on their part, as it turns out that a farmer who converted to what might have been called an industry-standard enriched cage system in 1999 would have found his cages declared non-compliant after 2008. Farmers have therefore had just four years to raise the funds and complete the transitional process. This makes it all the more impressive that Northern Ireland expects to be fully compliant with this directive on 1 January 2012, in line with other parts of the United Kingdom, while other countries, as we have heard, have made public that they will not be compliant in time, if ever.
	There was particular concern in Ulster arising from the fact that, under this directive, food manufactured using eggs from caged hens could still be tradable across the European Union. So we are back once more to the much invoked level playing field. Farmers in Ulster are looking for an assurance from the EU that products that use non-compliant eggs are at the very least clearly labelled as such for import and export so that farmers who invested in compliance are not at a serious disadvantage. There was a real risk that eggs from caged hens would continue to be used in the manufacturing of goods that could then be sold right across the European Union, pricing eggs from compliant farms out of the market.
	For many farmers in Northern Ireland, as elsewhere, much is at stake. I ask the Minister to ensure that there is close communication between his department and the Northern Ireland Executive as these matters advance to a conclusion.

Lord Grantchester: I would like to add my congratulations to the noble Earl on securing this debate at this time. All speakers have expressed concern as it was only on Friday 28 October that EU Ministers met to discuss how to address the problem of eggs being illegally produced in contravention of directive 1999/74, which lays down minimum welfare standards for laying hens and will take effect on 1 January 2012.
	We have heard tonight about the cost that the UK industry has borne to convert conventional cages to the new standard and that all of the UK will be compliant. I know that an egg producer in the next village to me, Betley, has invested £10 million to convert, with a continuing added cost of 5p to 6p per egg over and above the cost of production under a more conventional system. He will be looking to the Government to protect his investment from competition from producers in some overseas countries that do not meet the same standards to which he must abide.
	The EU commissioner for health John Dalli has confirmed that, despite predicted high levels of non-compliance, the Commission has no intention of postponing the 1 January ban. He is quoted as saying that the Commission,
	"will not hesitate to start infringement procedures in cases of non-compliance".
	Is the Minister satisfied that the Commission has the power to act? The industry is concerned that the Commission has not yet come forward with firm proposals for enforcement and penalties.
	Furthermore, from the meeting in Brussels on 28 October, there is concern that egg-production units with conventional cages will be allowed to continue until at least July 2012, subject to certain rules and that these rules are less than robust-for example, no non-compliance shell eggs to be exported outside national borders and all non-compliant shell eggs to be prohibited from being placed on the shell market as class A but are to be processed within that member state. However, if there is no processing plant or insufficient capacity in that member state, shell eggs will be allowed to be processed in a neighbouring member state and then returned. Such egg products could then be used in prepared food and products and exported. Could I ask the Minister who will monitor non-compliant eggs moving across a border, and who has the responsibility and by what process to ensure the egg is then returned?
	Could the Minister confirm whether any analysis of supply and demand has been undertaken to determine that there will not be any massive market distortions or a displacement effect on seconds from compliant producers? Has the Commission got robust data from all member states on the conversion status of their industries?
	In a batch-housing production system, the industry is also sceptical that the reduction in stocking density can be actioned between batches. At the egg and poultry industry conference, the Minister of State for Agriculture and Food in the other place welcomed the British Retail Consortium's commitment to ensure that all major retailers source their shell eggs and own-label products containing egg from producers with the new enriched cage system. What evidence will be available to consumers, and will any labelling system be put in place? Could I ask the Minister what action his department will be taking to ensure non-compliant shell eggs and egg products do not enter the market place? Is his department confident that there is ample consumer recognition of the industry's food assurance schemes and is there more it would like to see being done?
	The Minister will know that in the past certain countries have banned imports of certain foodstuffs-I am thinking of beef in particular. Has the Minister's department made any plans to ban the import of shell eggs or egg products from any particular country that poses a more extreme risk of being non-compliant?
	The UK industry and its farms in particular must be congratulated that they have met the demand for higher welfare standards. There is cross-party support for these measures. The consumer must also be sure that the food supply is legal, especially if a product has been procured overseas.

Lord Taylor of Holbeach: My Lords, there can rarely have been a more opportune moment to debate the egg industry than today and I would like to thank my noble friend Lord Shrewsbury for tabling this question and giving us the opportunity of talking about it this evening. As he and all noble Lords know, my right honourable friend Jim Paice, the Minister of State for Agriculture and Food, has been at a Council of agriculture Ministers in Brussels today dealing with this matter.
	As has been said, the provision in Council directive 1999/74/EC, which bans the keeping of hens in conventional-battery-cages from 1 January 2012, represents one of the most significant welfare advances across the EU, and we wish to see it effectively implemented across the European Union. My noble friend Lord Plumb recalled the debates in Europe that led to its introduction. However, I recognise that the cage ban is causing great concern to the egg industry. It is also a huge challenge for the Commission and other member states.
	I will address the issue of compliance first. The Government acknowledge the sterling job that the egg industry has done in preparing for the ban and the very big investment that it has made in converting to other production systems, which are more acceptable in terms of animal welfare. My noble friend Lord Lexden made evident the cost in human terms that this has meant for some farmers in Northern Ireland. Despite all that he told us, he said that Northern Ireland will be fully compliant with the directive. The vast majority of UK producers will be compliant by 1 January 2012. Of the remainder, we expect many producers to leave the industry at the end of this year.
	Perhaps I can help my noble friend Lord Shrewsbury by explaining just what the legal position is. Who will be in breach of the legislation if eggs from conventional cages are used in products after 1 January next year-the producer, the processor, the product manufacturer or the retailer? The egg producer would be committing an offence by continuing to keep hens in illegal cages after the ban and then illegally marketing his eggs as caged when they would be non-compliant. If processors, product manufacturers or retailers bought eggs that they knew were from illegal production systems, they too would be committing an offence. I also say to my noble friend Lord Greaves that the mandatory criteria of government buying standards will include the provision that neither eggs nor egg products from illegal producers should be used in any supply after 1 January 2012. The Government will take tough enforcement action against any UK producers found to be non-compliant after 1 January.
	The far more significant concern is that compliant UK producers will be disadvantaged by having to compete with cheaper eggs still coming from non-compliant conventional cages in other member states in 2012. We want to protect our producers, who have invested some £400 million in converting from conventional cages, which is equivalent to spending £25 per hen housed.
	The UK is the sixth-largest egg producer in the EU and the industry is an important contributor to the economy. The egg industry is one of UK agriculture's success stories and is used to responding to market signals, without receiving direct subsidies from the EU or the UK Government. A prime example is the way that the consumer demand for free-range eggs has increased dramatically over the past decade, and now around 50 per cent of the eggs produced in the UK are free range. The UK is 82 per cent self-sufficient in egg and egg products, with the remaining 18 per cent coming from other member states, in particular France, the Netherlands, Germany, Spain and Poland. Some of those countries have been mentioned as being non-compliant. Of the 18 per cent of eggs and egg products being imported, around 50 per cent is imported as shell eggs for use by UK processors, corner shops and caterers, and 50 per cent are imported as egg product, liquid and powder. The UK industry estimates that 23 per cent of the EU flock will remain in conventional battery cages on 1 January.
	What sort of problem areas do we see? The vast majority of shell eggs marketed through the major retailers are UK sourced. Small retailers, street markets and food service outlets are more likely to provide an outlet for imported eggs from illegal cages. The Government are confident that we have a robust strategy to enforce imports of shell eggs. The prime concern is with imports of egg products, where the supply chain is less transparent and more challenging to audit. Currently, 27 per cent of the egg products used each week in the UK are imported. Along with noble Lords, the industry fears that this percentage will increase and prices will be dragged down by large-scale non-compliance in other member states.
	Products which the industry considers most at risk from illegal egg imports from 1 January are Scotch eggs, sandwiches, quiches, cakes, gateaux and Yorkshire puddings, which use a high percentage of imported egg-I see my noble friend Lord Shutt raising an eyebrow at that information. The Government are working with the egg industry, retailers, food manufacturers and the food service industry in preparing their enforcement strategy to deal, not only with imports of non-compliant eggs from other member states, but also non-compliant domestic production.
	The British Retail Consortium has come out publicly in support of UK egg producers and guaranteed that conventional caged eggs will not be bought by the major retailers or used as ingredients in their own-brand products. They have put in place stringent traceability tests to ensure that they will not buy non-compliant eggs. Retailers that have made this guarantee include Marks & Spencer, Morrisons, Asda, J Sainsbury, the Co-operative Group, Tesco, Waitrose, Iceland Foods, Greggs, Starbucks and McDonald's.
	Tomorrow, my right honourable friend the Minister of Agriculture will meet the Food and Drink Federation, which represents food manufacturers, and the British Hospitality Association, which represents the food service industry, to see whether they would be willing to follow the retailers' lead. I hope that this reassures my noble friend Lord Cathcart that the trade in this country is determined to stick to sourcing eggs from legally housed hens.
	Ultimately, it will be the for the competent authority in each member state to take responsibility at source for ensuring that their producers no longer keep hens in conventional battery cages after 1 January 2012. If the Animal Health and Veterinary Laboratories Agency, the body that will enforce the conventional cage ban, has grounds to suspect that a particular consignment of eggs may have been produced in illegal conventional cages, then it will contact the competent authority in the member state to check if it knew whether it was sourced from a compliant producer. I can assure my noble friend Lord Greaves that traceability is a key responsibility placed on member states.
	Alongside the preparation of a rigorous enforcement strategy, we are still pursuing UK interests in Brussels. For well over a year, the Government have been at the forefront of efforts to convince the Commission that simply relying on infraction procedures against non-compliant member states will not be enough to deal with the negative effect that non-compliance would cause and that additional enforcement measures would need to be put in place to prevent market disturbance. On my noble friend Lord Greaves's question about strengthening the Food and Veterinary Office, the FVO clearly has a key role here, but relying on infraction proceedings alone will not be enough.
	We are pushing the EU hard to use all its available resources to ensure that a ban is implemented and enforced. In September, the Secretary of State wrote jointly with nine other concerned member states to the European Commission, urging it to act quickly. At the October Agriculture Council, the Commission ruled out the option of an intra-community trade ban. It is very disappointing that we have ended up with no legal solution to protect compliant producers from the large-scale non-compliance that there will be in January 2012.
	As my noble friend Lord Cathcart passionately observed, given the scale of non-compliance that we are expecting, the Commission is now looking for a robust enforcement approach that avoids large numbers of producers having to close down their operations and the destruction of millions of hens and non-compliant eggs. At the same time, we rightly demand that the Commission must protect all those producers who have complied with the ban and implemented a flagship animal welfare policy. The Government are contributing to ensure that any solution is as tight as possible to protect our producers.
	I can assure my noble friend Lord Lexden that we are working with the devolved authorities. Earlier today, Jim Paice, the Minister of Agriculture, fought our corner on this issue at a meeting of the Agriculture Council in Brussels. I regret to say that no agreement was reached, and there will now be further discussions on 29 November to try to find a solution.
	There have been some questions about a unilateral trade ban, which was raised by the noble Lord, Lord Grantchester. The Government have thoroughly investigated the possibility of taking unilateral action and bringing in a UK ban on imported eggs and egg products which have been produced in conventional battery cages in other member states. There are significant legal challenges in instigating a unilateral ban, but at this stage such a move is still on the table. We are also considering other measures that we could introduce swiftly.
	In conclusion-and I am sorry if I have taken more time than I should-I thank my noble friend Lord Shrewsbury and all noble Lords who have spoken in this debate. UK egg producers must not be put at a disadvantage for leading the way on animal welfare issues. They should be able to operate within a level playing field across the European Union.
	Sitting suspended.

Health and Social Care Bill
	 — 
	Committee (5th Day) (Continued)

Amendment 51
	 Moved by Lord Patel
	51: Clause 6, page 3, line 38, at end insert-
	"(c) must exercise its functions by overseeing sub-national clinical senates and networks"

Lord Patel: My Lords, in the absence of the noble Lord, Lord Walton of Detchant, I am very pleased to move the amendment on his behalf. I wish I had a better idea of what his purpose might have been in tabling the amendment. None the less, it is a good opportunity to explore the Government's thinking in establishing the clinical senate.
	It is easier to understand the purpose of the professional networks, which I have spoken about before. I think they are a good idea, and there should be more clinical and professional networks embedded in the health system. The cancer and cardiac networks are two good examples. However, when it comes to the senate, I am less clear about the Government's intentions. I know that the NHS Future Forum:Clinical Advice and Leadership report said that commissioning consortia-now called commissioning groups-and the NHS Commissioning Board,
	"should establish multi-specialty clinical senates to provide ongoing advice and support for their respective commissioning functions".
	It also said that independent advice from public health professionals should be available at every level of the system, but that is by the way.
	Therefore, we have a situation where the Future Forum suggested that clinical senates should be a way of getting advice to all the different new structures. In response to the Future Forum, the Government said that clinical senates will give advice to CCGs which they must follow in each area of the country. At the same time, Dr Kathy McLean, who led on the project, is leading another project and has issued a consultation letter to develop the role of clinical senates and clinical networks. Obviously the Government do not have a clear idea of what the clinical senates are for, otherwise why is Dr Kathy McLean leading the project and issuing a consultation letter?
	It is proposed that 15 senates will be housed by the NHS Commissioning Board. They will feed their advice back to the NHS Commissioning Board, although about what is not clear. In his two amendments my noble friend Lord Walton of Detchant wonders whether they might be useful in feeding the Commissioning Board and the commissioners advice about specialist commissioning. The senates will have a major say in advising CCGs on their commissioning plans, but their advice will be exactly that-advisory. Membership will consist of doctors, nurses and other health professionals, so it will be a large group. The senates are to be involved in quality aspects of clinical commissioning and an annual assessment of CCGs, and they will report on their annual reports and performance. They have serious work to do in monitoring CCGs, yet they are only advisory for CCGs.
	Future Forum suggested that clinical senates should provide advice and support for a range of bodies, including CCGs, the NHS Commissioning Board, health and well-being boards and others. Are senates not likely to end up as just another layer of bureaucracy? Therefore, what is the real role of all 15 clinical senates? Will they be involved in advising the NHS Commissioning Board in its commissioning role? Are they to be advisory for CCGs and check on the quality of their commissioning? Why are the professionals on the senate going to be from outside the commissioning groups' area of commissioning? The amendments are tabled to explore whether they will really have a role in commissioning specialist services.

Lord Hunt of Kings Heath: My Lords, I also have an amendment in this group. I say to the noble Lord, Lord Patel, that he anticipated the remarks of his noble friend Lord Walton remarkably well.
	Having argued against bureaucracy in the previous group of amendments, I am now about to argue in favour of putting senates on a statutory basis. I shall explain why. First, this was a very good outcome of the listening exercise. I think that because I am concerned at the Government's decision to abolish the strategic health authorities. It is what I call the Hagley Road issue. In 1948, the Birmingham Regional Hospital Board was established; its offices were in Hagley Road and throughout 60 years there has always been something there. It may have been a regional health authority, a regional hospital board, a strategic health authority-call it what you will-but there has always been a regional outpost of the department acting essentially as a leader, with a positive role in looking at the region as a whole, ensuring that its services were cohesive and had proper direction and that, by and large, it was self-sufficient. That is to be removed and we are going to get large SHA clusters which will cover a much larger part of the country. Although we do not know the size of the clinical commissioning groups, they will clearly cover much smaller population areas.
	I believe that there is still a need for a mechanism whereby strategic leadership can be given over a region, and I see the clinical senates as being the best approach to that. Noble Lords have spent at least two days debating reconfiguration and are concerned that these difficult decisions often have intervention from the centre. Clinical commissioning groups will be too small to take on the kind of strategic leadership that is required. When you are trying to establish in a region where the super specialty and tertiary services should be and trying to come to a view about how many A&E and emergency departments you need, you require a body that can take a strategic overview. The clinical commissioning groups are too small to do that. They could, of course, possibly come together in a kind of federated meeting to try to resolve those kinds of issues, but that could prove to be very difficult. Therefore, the senates could have an important role in setting some of the parameters and giving strategic leadership to a region.
	However, as the Government intend them at the moment, these will be informal groups of people who could easily be ignored by the clinical commissioning groups, by the health and well-being boards, by the deaneries and by all the organisations that have an influence on the way in which the health service is going. My amendment is designed to set out a more structured approach to ensure that clinical senates are created as bodies corporate, that they are properly accountable to the national Commissioning Board and that they have the ability to give strategic leadership and have some oversight of the work of clinical commissioning groups.
	I suspect that my amendment will not find favour with the noble Earl but the point about the need for strategic leadership in a region is important. I fear that the super SHA clusters will be too large to do that and the clinical commissioning groups will be too small.

Baroness Jolly: My Lords, I would like to speak to Amendments 51 and 84, but before I do, I have an interest to declare. I am chair of the Specialised Healthcare Alliance, an organisation campaigning for those with rare and complex conditions. The move to commissioned services for this particular group of patients by the NHS board is really welcome. It is the first time that there will be a common standard across England under the auspices of the board. However, we are not totally clear about the composition of the senates or their roles. I am not sure that the amendment of the noble Lord, Lord Walton-who is not in his place at the moment-actually gets to the meat of this. There is concern that specialised services within senates might get lost. If a specialised senate with expertise and integration were set up, that might be useful to this group of patients, but more often than not networks are where the specialised services go to for the expertise. We welcome the commitment to ensure that networks stay as they are and possibly expand. Maybe a network could set up a task and finish group to look at the problems around specific conditions. I would be grateful if the Minister would make the role of the senates clear. Would they have a role in specialised commissioning? Similarly, I would be grateful if he would shed some light on the ways in which the board will commission specialised services in general.

Baroness Murphy: My Lords, I must confess that when I first read about clinical senates, I thought, "This is a great solution". But what is the question? The problem came home to me very much when visiting the New York mental health commissioning services and saw the great difference in their approach. Mental health is commissioned by the public purse for a largely public service everywhere in the world, so it is a good way of looking at how people commission differently in different places. The big difference between New York's system of commissioning mental health services and ours was that they had clinical specialists involved on a day-to-day basis who could never be second-guessed by the provider system. That is because they were recognised experts who usually had run a service themselves and were very respected nationally or locally. They were incorporated into the commissioning group. The same was true of public surgical services, public health services, and so on. That was very impressive.
	Therefore, when I heard about clinical senates, I thought that this could be the way to provide that kind of serious expertise from a region to clinical commissioning groups. However, it does not seem to be developing quite that way. The noble Lord, Lord Hunt of Kings Heath, is very optimistic with a slightly grandiose idea of what these clinical senates might do. I would love to share his optimism but I remember those dreadful regional medical advisory groups. I know that the noble Baroness, Lady Emerton, will remember them, because we dealt with the same clinical regional advisory group for the south-east Thames. They were dire; they were the lowest common denominator of time-serving BMA-No, I am going to be very careful now. I do not want to be too rude, but on the whole, they were not the edifying cutting edge of specialties.

Lord Patel: Psychiatry.

Baroness Murphy: Even the psychiatrists were not. I can remember this group of people being pretty darn useless. You would send up a proposal; they would look at it; they did not like it because it was not in their best interests as a specialty and they would send it back again. I can see that my colleague, the noble Baroness, Lady Emerton, agrees with my every word.
	I am a little concerned about what these people are going to do. Will they provide cutting-edge, evidence-based expertise of the best kind to local commissioners? Will they be a talking shop? Will they be a regional medical advisory group?

Lord Warner: My Lords, I rise to reassure the noble Baroness, Lady Murphy, and restore her confidence in the Labour Benches on the subject of senates. If the Conservative side can have the Mawhinney-Howe dialogue, why should we not have the Hunt-Warner dialogue on senates?
	I can well understand why people would like to be a senator. It sounds very grand. It would be good to put on your CV that you are a member of the senate of wherever-even if it is Birmingham. To some extent, I can understand why the Future Forum thought it would be a good idea to have senates. I can imagine it received a lot of representations from specialists in various parts of the country that perhaps these GP commissioners, as they were then known, were getting a little uppity and needed to be curbed a little and put in their place. Why, then, not give a little more space to the people who really know about these things-the specialists-and bring them together in senates? Yet, since 2006, thanks to the helpful report by Sir David Carter on specialist commissioning, we have gone a long way in putting in place a sensible way for dealing with regional specialties and, on top of that for very rarefied stuff, a national commissioning capability. That has not been around for long. It would not be a bad idea to try to keep some of that learning experience together as we move into this brave new world.
	I do not have any problem with networks. Networks have been a proven success. They have done a lot of good and there is a lot to be said for trying to reinforce them, even to put some wording about them in the Bill. But I struggle with senates. We need a really good explanation of what they are out to do. The noble Baroness, Lady Murphy, put her finger right on the button: it is a very good solution but what is it a solution to? I hope we can have some enlightenment on that from the Minister.

The Archbishop of York: In my day-to-day life, I have to do what they call "oversight". The trouble with oversight is that it is always remote. The person who comes on the round is the parish priest or the diocesan bishop. The moment you begin to take oversight seriously from a distance, you are in real trouble. How do you know that the delivery of what you want will work? I am not so certain that I want this Commissioning Board to have oversight of both clinical issues and the senates. That would lie somewhere else, not with the board. It is to the board that Monitor, NICE, clinical senates and networks, and the Care Quality Commission actually report. I can understand the other factors in the Bill but the moment you include the business of,
	"overseeing sub-national clinical senates and networks",
	you are in real trouble. What is that, by the way? I remain uncertain. We certainly need a clear spelling out of what senates are for. That is a separate question from whether the board should oversee their work, let alone if we understood it.
	I am not one to suggest that this amendment is helpful. What would be most helpful would be to hear from the noble Earl what are the senates, what are these networks, and where you would locate the whole question of accountability and responsibility. I do not think it is the board; otherwise you are giving it a much bigger function when it already has five functions; and there are further provisions in the schedule. If you really want the board to fail, add on more work. So my view is that it should not have oversight of the sub-national groups. However, I am still confused. Will the noble Earl tell us what the senates are for? Networks I can understand; but what are the senates for? If he explains, we may actually see that this amendment is redundant.

Lord Kakkar: My Lords, I would like to ask the Minister what the potential relationship is between clinical senates and an expansion of academic health science networks, or academic health partnerships, that may be proposed from the ongoing chief executive of the NHS review of innovation. It is suggested that that review may endorse an expansion of the current academic health sciences network. I must remind noble Lords of my own declaration and involvement in University College London Partners academic health science centre.
	As I understand it, the purpose of clinical senates is to provide support in helping clinical commissioning groups to draw on expertise available from a broader group of clinicians and disciplines within their region to help inform ultimate clinical commissioning decisions. However, if the proposal that the current network of five academic health science centres is expanded into a network of broader academic health partnerships, serving a population of about 3 million to 4 million for each partnership, within those partnerships there would be a broad range of academic and other disciplines. They would be represented in a health partnership or network fashioned on the current academic health science centres to be able to deliver expertise and advice on commissioning and provide the opportunity to aid in a transformation of health practice pathways of care, to provide a potential home for the education and training functions that will need to be rolled out at a sub-national level, and also promote interest with regard to research and innovation.
	Under the circumstances, if academic health partnerships were to be expanded and promoted as a result of the ongoing innovation review, could not the responsibility suggested for clinical senates be undertaken by the academic health partnerships and current academic health science centres? This would avoid the need for yet another grouping or layer of bureaucracy to be created within the systems responsible for the commissioning and provision of health services.

Baroness Williams of Crosby: My Lords, if I may, I will pursue what has been raised by the noble Lord, Lord Kakkar, and also, in some ways, by the point made by the most reverend Primate the Archbishop of York. I could not help thinking that perhaps protesters count among the networks and the people responsible for running St Paul's count as part of the commissioning group. With that in mind, I will pursue also what was said by the noble Lord, Lord Hunt. If you look at his Amendment 224A(6), he helpfully refers to the clinical senate having,
	"the function of establishing and maintaining a system of clinical networks",
	in the area. I think that should be applauded. I am very impressed by the way in which networks at their best not only extend information very widely among patients with a chronic condition but bring the patients into the discussions about what should be done in their situation. It becomes a huge educational and, indeed, morale-boosting process. So on subsection (6) I think that the noble Lord, Lord Hunt, has put his finger on something that could be very important and where the clinical senate would give clinical backbone to the deliberations and thoughts of the clinical network. That is almost, I suppose, what we are all trying to achieve.
	I am not so clear about subsection (8) of Amendment 224A, where the noble Lord, Lord Hunt, has effectively given the clinical senate something of a veto over the commissioning group. I am not sure that that is wise, as that plays right into what the noble Lords, Lord Patel and Lord Kakkar, were saying about creating yet another layer of bureaucracy. I think that would be unhelpful and might indeed feed into a certain self-importance on the part of people who call themselves senators, whether clinical or merely political.
	I would like to ask the Minister, bouncing off the amendment from the noble Lord, Lord Hunt, whether, looking through that amendment, he does not find parts of it that are helpful, useful and constructive. It would make a clinical senator a significant part of the whole structure of the relationship between patients and clinicians. Whether he needs to press ahead with provisions that would bring in the senate as a requirement of the decision-making process of the commission is much more questionable. I am playing a kind of ping-pong, in which the ping of the noble Lord, Lord Hunt, has to go to the pong of the noble Earl, Lord Howe.

Lord Hunt of Kings Heath: Can I accept the invitation to come back on this? The reason why I am interested in the other bit of my amendment is that it is essentially about the strategic leadership that needs to be given to reconfiguration issues. When we debated the powers of the Secretary of State, a number of noble Lords complained that Ministers intervened in reconfiguration, which usually means the closure of services, perhaps emergency services, and their concentration around specialist hospitals. They are very contentious. As noble Lords have observed, MPs seek ministerial intervention, which is perfectly normal and democratic. In the new structure, there is no one to really lead this at a semi-national or regional level. The CCGs are far too small; they will not be able to come together to sort out how regional services should be operated, or the number of A&E departments you need within a region. The national Commissioning Board is far too big; it is national. That is why I think that there is room for some regional mechanism. The clinical senates seem the nearest that we can get to that. I do not see them as being like the old-style regional medical advisory committees; I see it as being a rather more dynamic process than that.

Baroness Williams of Crosby: I thank the noble Lord for his typically articulate and thoughtful response. The idea of clusters coming together in what one might call semi-regional groupings is a better way forward than bringing regional senates in as a way to resolve the problem that he rightly talks about of bodies being too small or too large.

Baroness Cumberlege: Can I also ask the noble Lord, Lord Hunt, about his amendment, in which he proposes setting up another very strong bureaucracy? It is a corporate body, known as a clinical senate; I presume, because it has a proper officer, that it will have a range of officials. It is suggested that it should revalidate doctors within the area, but I am wondering how that would work with the GMC and others. It will maintain a whole system of clinical governance within clinical commissioning groups and also authorise some of the clinical commissioning groups.
	I can understand the noble Lord's wish for some strategic leadership. I have been a regional chairman-and I have to say that our medical advisory groups were really excellent compared to those of south-east Thames. We had really good ones. But I am anxious about this matter. I sense that this is simply a probing amendment, because the membership of what the noble Lord proposes would be extremely bureaucratic. I understood that these were advisory boards, and that it was to try to get some of the clinical input from the acute centre into the commissioning groups so that they understood perhaps more clearly what they were commissioning in terms of acute services.
	I very much look forward to what my noble friend is going to tell us as to how he sees this issue. But I must say to the most right reverend Primate-I think I have got that right-that if he can manage the Anglican church he really could manage the National Health Service.

Baroness Finlay of Llandaff: I wonder whether this is one of the occasions where the organigram that we were discussing previously in Committee might be helpful. I would be grateful if the Minister could tell us in his summing up when we might expect to see that diagram.

Earl Howe: My Lords, we heartily endorse the important role that clinical advice will play in supporting the NHS Commissioning Board in fulfilling its duties and carrying out its functions effectively. We fully expect clinical networks and the new clinical senates to make a vital contribution to this.
	The Government intend that doctors, nurses and other experts from across health and social care will form clinical senates to give expert advice to commissioners. They will do this principally, although not exclusively, in two situations: senates will have a role in the authorisation of clinical commissioning groups, as well as having a role in advising on significant service change on a large geographical scale. Existing clinical networks will also be taken forward and developed and will advise on how specific services can be better designed to provide integrated and effective care. The Government are committed both to retaining and strengthening clinical networks and to using them to help ensure that a range of professionals play an integral part in the clinical commissioning of patient care. The networks will include patient and carer representatives that exist in areas such as cancer care, so that they cover many more areas of specialist care. Networks will have a stronger role in commissioning, in support of the board and local clinical commissioning groups.
	Although we fully agree with the noble Lord, Lord Patel, in highlighting the important role that both clinical networks and senates will play in the new system, I cannot support his Amendment 51, nor can I support Amendment 224A, tabled by the noble Lord, Lord Hunt. The reason why I cannot accept them is the same in each case: both of them would specify the roles of networks and senates in legislation. That would restrict the range of ways in which they can operate, which in turn would limit the value that is delivered for patients.
	Clinical senates and networks will not be statutory organisations, and that is why they are not referred to in the Bill. That, surely, is a positive thing. It gives them much needed flexibility in how they operate, maximising benefits for patients while minimising bureaucracy. This flexibility will allow both senates and networks to act as enablers of the commissioning system, supporting commissioners by providing them with expert advice. They will not act as another layer of management or administration which hinders progress; instead, the board will host both clinical senates and networks, allowing any supporting functions which can appropriately be shared to be organised with the least administrative bureaucracy. The review of the current system of clinical networks is identifying the features that deliver the greatest benefits, allowing the new system to build on these in a streamlined way that effectively drives improved quality and outcomes.
	The board will be subject to a duty, in the proposed new Section 13J within Clause 20, to obtain appropriate advice to enable it to discharge its functions effectively. We believe that this general duty is sufficient to ensure that it seeks appropriate advice, including, of course, clinical advice. In practice, clinical networks and clinical senates will form one way in which the board fulfils this duty.
	Clinical commissioning groups are also under a similar duty to seek appropriate advice. Although the board will host senates and networks, clinical commissioning groups will be closely involved in their design and functioning, as well as benefiting from their advice. It is expected that the board will issue guidance about avoiding conflict of interest where this might arise. The exact number of clinical senates is yet to be determined but they are expected to be able to offer informed, strategic advice across a health economy, which might suggest having around 15 across the country. Clinical networks will be based on patient flows rather than NHS boundaries, so variations in size will continue, but representation will always be appropriate to the remit of each network.
	Clinical senates will bring together a wide range of experts from across different areas of health and social care to provide cross-cutting advice on strategic commissioning decisions for broad geographical areas. The detail of the functions that clinical senates will carry out in support of commissioners is still being developed, but I think that they will come into their own particularly for strategic issues arising across a broader area than just at clinical commissioning group level. They could provide advice on the clinical aspects of commissioners' proposals for large-scale service change or reconfiguration-exactly as the noble Lord, Lord Hunt, indicated-where commissioners feel that a broader strategic view would be useful. We think that they will also have a role in the quality aspects of authorisation or annual assessment of clinical commissioning groups. As a result, although analysis is being carried out to determine the most appropriate number of senates, it is intended that they will operate across a wide strategic area.

Baroness Williams of Crosby: I have a quick initial question. If a CCG happens to be in the area of, say, a university medical school or medical hospital, how would the process of picking who would be on the clinical senate be handled?

Earl Howe: As I have mentioned, the senates will come under the wing, so to speak, of the NHS Commissioning Board. They will effectively be part of the board. While we have yet to receive details of how the board will configure itself sub-nationally, it will clearly have to do so in ways that make sense of the local commissioning and provider architecture in an area so, where you have a university, it might well be that medical experts from that university will be part of the senate. It is too early to say, but I look forward to updating my noble friend as and when I have further particulars.

Lord Hunt of Kings Heath: I stand as a supporter of the noble Earl on the concept of senates. He is not getting much support but I agree with the point that he made that if clinical commissioning groups feel that there needs to be a wider strategic view, say on reconfiguration, the clinical senate could provide useful support. The problem is that some clinical commissioning groups may not think that there is a need for a wider strategic view because they will simply seek to defend existing provision. My argument is that you may need a mechanism which is somewhat more proactive, and which can intervene in the way that the noble Baroness's wonderful South West Thames Regional Health Authority used to do.

Earl Howe: The noble Lord could be proved right. As I have said, we will see how the functions of senates are defined. That work is ongoing. The initial proposals for the design and implementation of senates are currently being developed and initial straw-man proposals are being tested with the intention of presenting a clear set of recommendations to the top team of the special health authority later this year, so-

Lord Warner: I am sorry to interrupt the noble Earl but I am still puzzled about where he and the department are taking this concept of the senate and how it fits in with the regional specialist commissioning set-up, which already exists and which has 10 regional commissioning capabilities aligned with the SHA areas. I am not clear about whether that work is to be folded into the senates. Is it free-standing? Are the lessons all to be lost, and what are the costs of this? What does hosting the senate mean in terms of costs, because there are costs to these regional bodies that are undertaking the work on specialist commissioning? I am at a loss to understand how these two elements-the senates and the regional commissioning capability that is there now-coexist and what the cost implication is of hosting senates alongside those.

Earl Howe: I will talk in a moment about specialised commissioning and I hope the answer to the noble Lord's question will emerge. Amendment 84, tabled by the noble Lord, Lord Patel, would require the board to commission highly specialised services, in collaboration with the sub-national clinical senates that are accountable to it.
	I will not rehash my arguments around Amendments 51 and 224A, but many of the same points will apply to this amendment. Specialised services are challenging to commission; they involve complex care pathways, small numbers of providers and very small numbers of patients with rare conditions. The new NHS Commissioning Board authority will be considering options as to how it does this, including the best form for its substructures. There will be the freedom to adapt these over time and, to ensure that progress is not lost, the board will be required under existing provisions to maintain the necessary focus of clinical expertise in these highly specialised areas.
	The noble Lord, Lord Hunt, asked how we ensure that clinical senates are not ignored; this is precisely why we do not want to prescribe their role in the Bill. We want senates to be enabling bodies, which is why we are inviting views on the type of advice they could provide to identify the functions of the board and CCGs where they would add value.
	The noble Lord, Lord Patel, indicated that he thought the clinicians on the senate would have to come from outside the clinical commissioning group area. That is not the case; he is not correct in that assumption. There may be slight confusion with the rules we set for secondary care doctors on CCG governing bodies, who must avoid conflicts of interest, hence the need for area restrictions in that context. Experts on clinical senates can come from, in theory, all or any areas of the country. The difference between the senates and regional specialist commissioning is that the latter focuses on specialised services and nothing else. The senates could, in theory, work across all services; the two are not designed to do the same thing. The senates will be quite high level. It is expected they will be about only 15 in number, and while they may be established in a certain form they can evolve over the years to conform to the requirements that are placed upon them.
	My noble friend Lady Jolly pressed me on the role of the board with regard to specialised commissioning, and I have already indicated in outline part of that role. The key point is that the board will maintain the necessary focus of clinical expertise and it will be under specific duties to obtain professional advice in the exercise of its functions. Under the regulations, the types of service the board will be required to commission will be kept under regular review. Work is going on at the moment to define what those services should be in the first instance, and I fully expect them to conform broadly to the specialised services national definition set. As my noble friend knows, the list of those services has historically changed over time and I expect the same will apply in the future.
	The noble Baroness, Lady Finlay, asked about the long promised organigram. In fact, our fact sheet on the overall health and care system does have an organigram in it. It includes the NHS Commissioning Board and describes how senates and networks will be hosted by the board. I refer the noble Baroness to that sheet. The noble Lord, Lord Kakkar, asked how senates will be different to academic health science centres in their focus. In short, AHSCs are partnerships of local academic and health bodies to support innovation and excellence in that area. However, they will not be impartial; they are by definition a vested interest. Therefore, they would not be the right bodies to offer the broader perspective on how services should best be configured across a region.
	I hope that noble Lords will be at least somewhat enlightened by the details I have been able to give about clinical networks and senates. As I say, this is work in progress. I make no apology for that. This was very much a recommendation that emerged from the Future Forum report. We have got on with the work needed to flesh out what these bodies should be, but we have a broad and, I hope, helpful idea of their role across the wider NHS system. I hope the noble Lord will feel able to withdraw his amendment.

Lord Patel: My Lords, I thank the Minister for his extensive reply. When I moved this amendment in the name of the noble Lord, Lord Walton of Detchant, I did not think there would be such enthusiasm to join in. I was surprised by the enthusiasm generated by his amendment, and I thank noble Lords who joined in. The most reverend Primate said this amendment was not necessary. I hope that he was not referring to the amendments that I had tabled, or I would say to him that my amendments were "zuri sana"-for those of you who do not understand, that means they were very good. He understands that.
	The noble Earl has, to a degree, clarified the Government's thinking on what the role of these senates will be. As he said, it is work in progress. Of course, we will need to wait and see what the details are. In the mean time, I beg leave to withdraw the amendment.
	Amendment 51 withdrawn.
	Clause 6 agreed.
	Amendment 52 not moved.
	Schedule 1 : The National Health Service Commissioning Board
	Amendments 52A to 57 not moved.
	Amendment 57A
	 Moved by Baroness Jolly
	57A: Schedule 1, page 277, line 37, at end insert-
	"(1A) The Secretary of State must make provision for a procedure whereby complaints about health and social care providers in England can be brought before the Board."

Baroness Jolly: My Lords, Amendment 57A is to do with reporting complaints to the NHS Commissioning Board. There are two distinct areas for complaints: complaints related to commissioning and those related to care or service delivery. In fact, they would filter through the board, clinical commissioning groups and local authorities. I include local authorities because, if we are talking about complaints about possible integrated services, we cannot decouple clinical commissioning groups from local authorities.
	In the far-off days that have been mentioned earlier in this Committee, before PCTs and foundation trusts were even thought of, most NHS boards had a complaints convener. I was one such person. We had a quarterly report back to the board. We reported back on complaints, but it is also worth putting on record and remembering that not only did trusts receive complaints but they received a lot of plaudits as well. You only have to wander around a hospital-I spent six months in my DGH as a visitor at the tail-end of last year-to see the number of cards of thanks sent in by relatives or by patients. Plaudits should get a mention, and we have far more plaudits than complaints in the NHS. Complaints, however, are important and should be reported back. In those days, they were reported back quarterly to the board, as they perform a useful function: they are a barometer of the institution. You can see what is working and what is not and where there are issues. They go up and down. They can form part of the performance dashboard and they are also critical for learning. An institution or trust can learn from complaints.
	Handling complaints is a delicate-and should also be a transparent-process. The NHS Commissioning Board is committed to transparency. Its role is overseeing service provision and so it should see a breakdown of the complaints that are arising within the service it oversees-not personal details of Mrs Gidden's hip replacement or Mr Patel's hernia, but an appropriate format that will reflect the health of the NHS. As the board also oversees commissioning, it should also see complaints that relate to an organisation's competence in commissioning. So, with that as the framework of my complaint, I wonder whether the Minister could clarify the nature of reporting such information to the NHS Commissioning Board. I am sure he will be happy to agree to its importance. I beg to move.

Baroness Wheeler: My Lords, I am pleased to speak on this group of amendments, in particular on Amendments 143A and 143B, on behalf of my noble friends Lady Thornton and Lord Hunt. I am also speaking to the clause stand part debate on Clause 275, which relates to the abolition of the National Patient Safety Agency.
	A critical function of the NHS Commissioning Board is to improve the quality of services and drive improvements in health and social care. A key way of achieving these objectives is learning from complaints information. There is a clear need for the NHS Commissioning Board to have meaningful comparable complaints data from service providers which can be used to help drive improvements in healthcare and strengthen the quality of services for patients and the public. This information can contribute significantly to an enhanced patient experience and enduring service improvement. It can enable the board to identify possible trends and patterns of risk and to take appropriate action through putting pressure on healthcare providers to raise standards and demonstrate how they have learnt from patients' complaints.
	Through this means, the board can hold providers to account for the safety and effectiveness of healthcare. Having this information is important because it identifies which providers are failing to learn from complaints. In collaboration with other organisations, such as the Care Quality Commission, Monitor, the NHS Information Centre and HealthWatch England, there will be the capacity to identify trends, themes and patterns of significant risk and respond through the commissioning process.
	While NHS complaints systems have been much improved and enhanced in recent years-my own Government introduced the current system in 2009-we recognise that the current systems for capturing complaints information require significant improvement. We know that a sadly recurrent theme at the Mid Staffs public inquiry has been that the complaints of patients and families were not heard. A system which ensures that complaints information gets transmitted to the people running the NHS would help to remedy this.
	Another crucial point is that, with the loss of primary care trusts, there is nowhere independent where complaints about GPs who are members of the local CCG can be investigated. It is clearly not appropriate for the CCG to investigate a complaint about a GP who is a member of the group.
	The Health Select Committee has supported the view that commissioning bodies should be the engines that drive improvement in complaints handling, in the analysis of data and leading change within the NHS. Amendment 143A, in particular, would enable the NHS Commissioning Board to play its part as a major service commissioner in developing more meaningful NHS complaints procedures and information, establishing a duty on Monitor to publish information.
	Amendment 143B is a probing amendment, which would delete the board's proposed functions in relation to information. This is in the context of our support for the continuation of the National Patient Safety Agency's much valued independent role. The National Patient Safety Agency provides a vital function under its current remit, managing the National Reporting and Learning Service, the National Clinical Assessment Service and the National Research Ethics Service. The NPSA acts as an umbrella organisation, providing a valuable overview of patient safety incidents by collection and analysis of data, and monitoring to ensure that lessons are learnt that can be fed back and used to improve patient safety.
	Under the National Reporting and Learning Service, the NPSA receives confidential reports on patient safety from incidents from healthcare staff across England and Wales, and oversees the independent processes of clinicians and safety experts who analyse these reports to identify common risks to patients and opportunities to develop improvements in care and practice. However, under the proposed new arrangements, the NPSA is to be dismantled and split up. On these Benches we are totally opposed to this. I ask the Minister how the information monitoring and service that it provides can be provided by the separate bodies that will now span across these issues. The NPSA's value is as an arm's-length body that is respected and valued by the NHS for its independence, expertise and the service it provides. Therefore, I also ask the Minister how he will ensure that there continues to be an overview, information and reporting system for the important functions currently undertaken by the NPSA.

Lord Whitty: My Lords, I intervene briefly in this debate to ask the noble Earl whether, in his reply, he could perhaps cross-refer to a later section in the Bill, which deals with the role of one of the entities to which my noble friend Lady Wheeler has just referred, namely HealthWatch England. In any procedure for complaints, whether about treatment or the ultimate effects of commissioning on patients and the quality of service, an independent body that represents the views of the users of the health and social care system is required. There is a whole group of relevant amendments, but it is the last group printed on this list so we will probably not reach it much before Christmas. Nevertheless, within that group is a strong line that HealthWatch England should be an independent body, which means independent not only of the providers but of the regulators. In any proper complaints system-although I do not suggest that this is the only channel for complaints-you need an independent consumer view. This has stood the test of time in several other sectors. It would be a major role for HealthWatch England if it could be built into the kind of clear procedure to which the noble Baroness, Lady Jolly, referred.

Earl Howe: My Lords, this has been a valuable debate on what is an important topic by any standards. It is vital that patients feel able to raise complaints where services are not good enough. It is equally important that there are appropriate systems for ensuring that complaints and safety incidents are effectively monitored and addressed, and that wider lessons are learnt.
	Amendment 57A would require the Secretary of State to create a new procedure, whereby complaints about both health and social care providers could be brought before the board. Amendment 143A would go further by giving the board a more specific role in collecting and analysing information relating to complaints about both the provision of health services and commissioning decisions by the board or clinical commissioning groups, and making this information available to the public. The current NHS and adult social care arrangements for handling individual complaints were developed to make the process of complaining quicker and simpler, and to put the focus on meeting the needs of the complainant. It is important that all NHS organisations view and manage complaints in a positive manner and use the information obtained to improve service delivery.
	Under the current regulations, a complaint about poor service provision may be made either to the service provider or to the commissioner of that service. It is important that people have that choice. Someone may be deterred from making a complaint to the service provider if they consider that it may impact on their future healthcare provision. We consider it right for these general principles on complaints handling to be carried forward into the new system architecture. In future, we envisage that complaints about service provision would be made to the service provider, or to either the local clinical commissioning group or the NHS Commissioning Board, depending on which had commissioned that service. They would also deal with complaints about how they have performed their own functions.
	Of course, where it proves not possible to resolve a complaint locally, the complainant has the right to refer the case to an independent arbiter. In the case of an NHS complaint, this referral is to the Health Service Ombudsman. The system of handling complaints will therefore continue to operate largely as it does now. The arrangements for monitoring complaints will also be similar. The NHS standard contract already requires all providers to report complaints information to commissioners. This information is collected by the NHS Information Centre and would be available to the NHS Commissioning Board. This is then discussed as part of the clinical review meetings between commissioners and providers, who are required by regulations to implement learning from complaints and other incidents. It will be vital that the NHS Commissioning Board is able to identify any emerging trends from this information.
	In reply to the noble Lord, Lord Whitty, the board will be assisted by both the local healthwatch and HealthWatch England, which will act as a conduit for the views of service users about their experiences of complaints handling. It will also be able to make recommendations to providers and commissioners about how services and procedures could be improved. There will be a duty on NHS organisations to have regard to the recommendations of the local healthwatch, which will also put pressure on providers and commissioners to improve.
	Finally regarding these amendments, the noble Baroness, Lady Wheeler, makes the valid point that it is important that information about complaints is made available to the public. Patient and service-user generated information, which includes complaints as well as information collected from patients and staff through surveys, real-time feedback, ratings of services and patient reported outcome measures, are all vital in helping patients to make informed choices about their care.
	Separate arrangements currently apply in reporting patient safety incidents that have or could have resulted in harm to a patient. These are reported in anonymous form through the National Reporting and Learning Service, operated by the National Patient Safety Agency. Safety has to be the key priority of all those working in the health service. We cannot allow it to be an add-on or an afterthought. Patients rightly expect that any service provided with NHS funding will be safe.
	For this reason, we want to put safety at the heart of the NHS by transferring these functions from the NPSA to the NHS Commissioning Board. Clause 275 therefore makes provision to abolish the NPSA as part of our plans to reduce the number of arm's-length bodies. Instead, new Section 13Q, which Amendment 143B seeks to remove, gives the NHS Commissioning Board responsibility for those functions currently carried out by the National Patient Safety Agency. This is in relation to collecting information about patient safety incidents, analysis of that information and sharing the resulting learning within the NHS and more widely.
	Safety is, of course, another of the core domains of quality. We believe that the NHS Commissioning Board, as the body that will be legally responsible for ensuring continuous quality improvement in the NHS, will be best placed to ensure that this learning is translated into improved practice. Its unique perspective will allow it to ensure that appropriate levers are used to drive safety improvement across the system. Bringing safety right into the core of commissioning activity in this way and is the most powerful way of driving a safety agenda through the NHS.
	While I have sympathy with the intention behind these amendments, I hope I have reassured noble Lords that our reforms will ensure effective systems for reporting complaints and safety incidents which will enable this information to be shared more widely and will maximise the chance of it translating into improved practice in future.
	The noble Baroness, Lady Wheeler, asked me whether I thought that clinical commissioning groups should handle complaints about their member GP practices. As the NHS Commissioning Board will commission primary care services, complaints about a primary medical provider would be addressed either to the provider itself or to the board, not to the clinical commissioning group. Of course, anyone can raise a complaint with the regulatory bodies if they choose to do so.
	In the light of what I have said, I hope that my noble friend and the noble Baroness will agree to withdraw their amendments.

Lord Patel: Before the Minister sits down, will he please confirm that the primary care doctors and the primary care team will also be obliged to report patient safety incidents?

Earl Howe: My understanding is that that is the intention. The clinical commissioning group will wish to monitor the quality of service provided by its member practices and the outcomes that those practices achieve. As part of that monitoring we fully expect that safety will be a core component.

Lord Greaves: Before my noble friend replies to this group of amendments, I hope that I may ask the Minister a question on something on which I confess total ignorance. The Minister said that many of the functions of the National Patient Safety Agency in collecting statistical information would be transferred to the national Commissioning Board. What other functions does it have and what will happen to them?

Earl Howe: Will my noble friend allow me to write to him on that point?

Baroness Jolly: I thank the noble Earl for his reply, the noble Baroness, Lady Wheeler, for her commitment to quality and the noble Lord, Lord Whitty, for the patient voice input. I beg leave to withdraw the amendment.
	Amendment 57A withdrawn.
	Amendments 58 and 59 not moved.
	Schedule 1 agreed.
	Clause 7 : Clinical commissioning groups
	Amendment 59A
	 Moved by Lord Whitty
	59A: Clause 7, page 4, line 15, at end insert-
	"(1A) The areas covered by clinical commissioning groups in respect of general primary care shall, as far as practicable, coincide with local authority boundaries.
	(1B) The requirement under subsection (1A) may be modified where clinical commissioning groups provide specialist services."

Lord Whitty: My Lords, I apologise to those I informed that I would not be here to move Amendment 59A-I am here and so I will.
	Noble Lords will probably appreciate that I have severe misgivings about aspects of the Bill but the amendment attempts to build on parts of the Bill of which I largely approve. The devolution of commissioning is important, but the later provisions in the Bill which associate issues of public health and well-being more clearly with the role of the health and social care system are also important.
	When we are talking about configuration in the sense of bureaucratic bodies, it is important to try to build into this a relationship between what are mainly local authority services and those services which will be commissioned by the new commissioning groups. The original form of the commissioning groups in terms of GP commissions has been altered somewhat but there will obviously be quite a number of them. We do not know how many of these commissioning groups are envisaged by the Government. This amendment attempts to say that there ought to be a relationship between commissioning groups and the local authority boundaries within which they operate. It is intended to be a relatively flexible operation, although it would be very sensible in many areas for there to be a total coincidence in coterminous boundaries between commissioning groups and local authorities. In others, there may well be more than one, but I still think some recognition of a relationship with the local authority services is important. It is important not only in the provision of social care and dealing with the developing conditions of individual patients and users, but for environmental health issues, on which I have later amendments. The public health service should ensure that the commissioning authorities recognise the importance of work in the public health area and the need to co-operate with the public health authorities.
	It is actually quite difficult to get the National Health Service, at both local and policy level, to take into account in its operational work the need for a public health dimension. There have been some significant improvements in this relationship in recent years, but they need to go further. I am therefore suggesting that, in principle, we should ensure that there is a relationship between the commissioning groups, the public health authorities and public health and well-being committees, and the local authorities that provide social care and public and environmental health services. It is intended to be reasonably flexible. Clearly such coterminosity, if that is a word, would not apply to specialist commissioning groups and, as I have said, I am not suggesting that there should be only a single commissioning group within each local authority area; although there would be advantages in that, it would cut across a lot of what the Government are attempting to do. I think, however, that somewhere in this Bill-not necessarily in the precise terms of this amendment-there needs to be a very clear relationship written in between the public health boundaries and the commissioning boundaries as they are envisaged in the new configuration. I beg to move.

Lord Rea: My Lords, following the noble Baroness, Lady Finlay, I raised this issue briefly on the second day of Committee. I felt, however, that the Minister only gave a partial answer. CCGs must have an "area" as set out in their constitution, but there seems to be nothing in the Bill which defines the limit of this area or its basis other than that CCGs will cover the registered practice population of the GPs sitting on the CCG. This will result in very untidy boundaries which will interdigitate with a variable number of other CCGs.
	However, proposed new subsection (1A) in Clause 10(3) says that a clinical commissioning group has responsibility for other people resident in its area but not registered with a GP-homeless people, rough sleepers, asylum seekers, et cetera. A geographical boundary for those people is therefore implied. Can the Minister say how this boundary is to be delineated? Will it coincide, as my noble friend has suggested, with the local authority, or with the former PCT-which in fact in 85 per cent of cases will be the same as the local authority boundary-or will it have some other basis? There is a strong case for-sorry about this word again-coterminosity with local authorities. They provide many of the services on which GPs depend. In fact, they are an integral part of primary care, such as social services and community health services, and public health, including maternal and child welfare services. They are especially important as, under the Bill, local authorities will all have their own director of public health. There are a number of services which were formerly provided by PCTs on a geographical basis: for example, ambulance and emergency services, genito-urinary medicine clinics, and drug and alcohol services. These are by no means all the services which CCGs will have to commission or co-operate with. What arrangements will be made for the area that these services will have to provide for?

Lord Kakkar: My Lords, Amendment 60 is in my name and that of the noble Lord, Lord Patel. It proposes to deal with the anxieties over real and perceived conflicts of interest that might exist in the functioning of clinical commissioning groups. The amendment proposes that:
	"The Secretary of State must publish, and may from time to time revise, a code of conduct for all clinical commissioning groups ... The code must, in particular, incorporate the Nolan principles ...'The Nolan principles' means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life".
	It is important to take the opportunity to explore the issues around potential conflicts of interest and the anxieties that these raise. The reason is very simple. Clinical commissioning groups will be new public bodies. They will have by large measure a large number of primary care practitioners as their membership. Primary care practitioners, GPs, will have responsibility for delivering care and have very special and cherished relationships with their patients in terms of promoting and guarding the interests of their patients. Moving forward, they will have new responsibilities for the commissioning of services. A potential anxiety exists under those circumstances.
	For many other statutory bodies in the public sector involved in healthcare, we have dealt with the problem of potential conflicts of interest by ensuring that those organisations and those who serve in those organisations are obliged to conduct themselves in a way consistent with the seven principles of the standards in public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Those seven principles are very powerful indeed.
	On 14 April I put a supplementary question to the Minister at Oral Questions about whether clinical commissioning groups would be obliged to follow the Nolan principles. The Minister stated that, since they were going to be public bodies, they would be obliged to do that. As they are new public bodies, many of those that are going to serve in important capacities in clinical commissioning groups will have little experience of public life. Yet they will have very important responsibilities and have to deal with the sensitivities and anxieties of patients, because they will both serve in capacities on clinical commissioning groups and continue to serve as patients' principal caregivers and primary medical practitioners. We need to find a way of ensuring that those anxieties are overcome.
	In many other situations, we have dealt with that through these seven basic principles. Indeed, the Parliamentary Standards Act 2009 was designed to ensure that anxieties over the conduct of Parliament could be dealt with in such a way as to satisfy the public more generally that there was transparency, and that those serving in public life in this Parliament had no doubts about their obligations and responsibilities. The Parliamentary Standards Act 2009 includes a commitment and requirement to adhere to the standards in public life defined in the Nolan principles. I therefore believe it might be an important opportunity to overcome the anxieties that attend the question of potential conflicts of interest in terms of the conduct of clinical commissioning groups for the same approach to be taken with regard to this Bill, and to include a specific reference to the Nolan principles in terms of the conduct of clinical commissioning groups.

Lord Hunt of Kings Heath: My Lords, clinical commissioning groups are, of course, one of the main building blocks of the Government's proposed changes to the National Health Service and I support my noble friend Lord Whitty when he argues for the need for population-based bodies at that essential local level. However, I will follow the noble Lord, Lord Kakkar, in looking at issues to do with corporate governance in clinical commissioning groups. I am concerned whether the corporate governance structure will be sufficiently robust. Will clinical commissioning groups be sufficiently accountable to the public? What safeguards will be put in place to ensure that clinical commissioning groups operate in the public interest?
	Schedule 2 sets out the details of the governance structure. Clinical commissioning groups will be bodies corporate with a constitution and a procedure for decision-making; an accountable officer and audit and remuneration committees are to be appointed. That is fine as far as it goes but I hope the noble Earl will use this opportunity to clarify what effective corporate governance structure is to operate. My Amendments 175CA and 175CB seek to do just that.
	On Amendment 175CB, I seek guidance and reassurance about the composition of the boards of clinical commissioning groups. On every other board in the NHS the non-executives are in a majority. Will the noble Earl confirm that that will be the case with clinical commissioning groups? If not, why not? I follow what the noble Lord, Lord Kakkar said: surely, by any definition, GPs are the least experienced in any form of corporate governance in the health service? Therefore, given that they are the least experienced, is it right that they should be subject to so much less scrutiny and challenge than those other organisations in the National Health Service which are hugely well versed in corporate governance? At the very least the chair and vice-chair of the clinical commissioning groups should surely be lay people to ensure that the public interest is represented.
	There would be considerable merit in ensuring an external appointments process. I have suggested here the NHS Commissioning Board but there may be other suggestions. All experience with public bodies shows that if boards are responsible for deciding on their membership you will often run into trouble. We have seen this in the education sector, with corporations of colleges simply deciding themselves who should be appointed and who should replace those who retire. Simply leaving clinical commissioning groups to decide on their membership is a recipe for deep trouble, particularly when the temptation for CCGs will be to spend resources on themselves, on their constituent GPs. The issue around public interest and conflict of interest will become a keen problem and, without strong, effective corporate governance, we may well run into great difficulty in the future.
	There are probing amendments around membership but, in relation to Amendment 175CA, I would like to know whether the noble Earl feels it is appropriate that local authorities should have some kind of representation on the boards of clinical commissioning groups. Amendment 175CA in particular draws attention to the role of district councils in two-tier areas. That is because clearly the principal local authority will be the host of the health and well-being boards. There will be concern, particularly in rural areas, if the non-metropolitan district councils do not have some involvement. I at least pose the question as to whether they may have some involvement at the clinical commissioning group level.
	My principal amendment is Amendment 175D which concerns the accountability of clinical commissioning groups. I do not understand how those groups will account to their patients. As a patient, what do I do if I do not agree with the decisions of the clinical commissioning group? What if I think the decisions made by my clinical commissioning group put me at a disadvantage compared to the decisions made by a clinical commissioning group in a nearby area? What if I think my clinical commissioning group, by its decisions, might affect the viability of my local general hospital? What if I think it is putting too many contracts with itself, bringing up this issue of conflict of interest? There is real concern about the conflict of interest issues around placing contracts with the GPs who form the constituent members of the clinical commissioning groups.
	How do members of the public hold the clinical commissioning groups to account? As far as I can see, the Bill is completely silent on that. The noble Earl may say that it is contained in the doctor-patient relationship, but I do not think that is true at all. My relationship with the GP is not about commissioning: it is about essential care. Frankly, there is already a risk that, because GPs are collectively going to commission, the doctor-patient relationship might be undermined in any case. That is because the moment we place commissioning decisions with GPs, there will always be a suspicion among patients that decisions they are making clinically will be governed by the needs of the clinical commissioning group and the need to ration resources. Clearly, the Secretary of State has said, and has been saying consistently, that the reason the budget has been put with GPs is to give control over the budget overall.
	I have put forward a model essentially based on the foundation trust model, which says that the members of clinical commissioning groups should be the patients who are on the lists of the GPs within that group. The membership should then vote for a governing body and the governing body should then appoint the non-executives on a clinical commissioning group. I am not completely wedded to that model: I just lifted a model that is currently in operation in the health service. My main point is that I do not believe that it is right and proper that a public body should simply be composed of one profession that is given enormous power-if you are lucky, there may be one or two non-execs on the board as well-accountable to nobody at all at the local level. There is no mechanism at all whereby I as an individual patient have any way of challenging the commissioning decisions of those clinical commissioning groups. This is a very important issue to which I am sure we will return. We have to make CCGs properly accountable.

Lord Patel: My Lords, I will be brief in supporting the amendment of my noble friend Lord Kakkar. I also support the comments just made by the noble Lord, Lord Hunt. I think it vital that local commissioning groups are accountable and conduct themselves according to the highest principles of public life. CCGs are legally responsible for the quality of their decision-making processes. Therefore, they need to be able to stand up to judicial review. The individuals making those decisions should be required to adhere to the highest standards of conduct for public officials.
	I know that, to a degree, the Government recognise this by raising the structures of CCGs-namely, the inclusion of lay and other professional members on governing bodies, the requirement for compliance, the principles of good governance and the pledges about public access to documents and meetings. While this work is being carried out, however, we need clarification about the methods of identifying and selecting lay and professional members of governing boards.
	The Bill also states that CCGs may pay members of the governing body such remuneration and allowances as it considers appropriate. Full autonomy may not be appropriate as it might undermine public confidence in the ability of members of CCG governing bodies to act in the public interest. Some degree of national guidance about fee scales might also be valuable.

Baroness Williams of Crosby: I will speak to Amendment 101A, in my name and that of other noble Lords. Before I do, I will say one word about the amendment spoken to by the noble Lords, Lord Kakkar and Lord Patel. I was pleased to hear what they both said because in a way it reflected the crucial nature of trust in the medical experience, the relationship between the patient and the doctor. That is at the centre of the ability to create a successful health service. They were absolutely right to emphasise that. Without going into detail, it is fair to say that the Nolan principles are becoming a kind of gold standard of the behaviour of people in public life. It is eminently suitable that that gold standard should be openly applied to those who are members of clinical commissioning groups at the local level. That will go some way to retaining the level of trust that exists between the medical profession and citizens.
	Turning to Amendment 101A, we do not want go over the ground again about membership of the board. This is, in a sense, the board in a miniature-the membership of the clinical commissioning groups. It is crucial that clinical commissioning groups are very close to their communities. The reason that my amendment refers in particular to a representative of the nursing profession is because almost nobody is ever closer to a local community than nurses. The information and knowledge that he or she carries can be vital to the working of the local clinical commissioning board. Also, nurses tend to be the recipients of any complaints there may be, so again it acts as a two-way channel. I also hope that we can bear in mind the importance of somebody with public health experience on a clinical commissioning board.
	I make one other, final remark. As evinced by amendments later on that we will come to discuss, the major guarantee of the behaviour of a clinical commissioning group will be transparency. I hope that when we come to look at the extent to which members of boards should declare any interests that they may have, and should be recused from any decision which might bear upon that interest, we will recognise that this is one of the most important elements in dealing with the point that the noble Lord, Lord Hunt, legitimately raised. The real concern is about the interests of individual GPs or groups of GPs in their own particular business-so to speak-and the way that that must be made absolutely plain before the clinical commissioning group takes a decision that can have any bearing upon the individual interests of individual members of the board.

Lord Warner: My Lords, I shall speak to Amendments 169, 171 and 174 in my name and that of the noble Lord, Lord Patel. I very much endorse the remarks made earlier by the noble Lords, Lord Kakkar and Lord Patel, and my noble friend Lord Hunt. There has been a huge amount of concern about the governance and accountability of clinical commissioning groups since they were launched upon a slightly unsuspecting world. That is not to say that it was a bad idea to have them, but a large number of questions have been legitimately asked about how they will be held to account for large sums of public money and how they will govern themselves, given in particular that they are a new type of public body. We have been unsure from the beginning precisely how many of them will emerge. It seems that there are now in the order of 200, or 250 or something like that, but we are not quite sure how many there will be eventually. Some of them are quite small and some will be quite big, so they are quite variable in their scale of operation.
	The conflict of interest issue has come up repeatedly. I cannot remember how many events I have been to where that issue has been expressed. There is also the fact that these bodies are untested. They are different in kind from many other public bodies that there have been. The theme running through my three amendments is about trying to improve the governance and accountability of clinical commissioning groups, given the large amount of public money that they will be spending-the collective expenditure of these particular groups runs into tens of billions a year.
	Amendment 169 seeks to ensure that a clinical commissioning group not only has a governing body but has,
	"an accountable officer who is the most suitable senior"-
	I emphasis "senior"-
	"employee of the group".
	I can appreciate how difficult it may be for a group of clinicians to agree who should be the chief executive. I also have no wish to impose an overly rigid management structure on clinical commissioning groups, particularly in their early days. However, I am old-fashioned enough to believe that public bodies handling large sums of public money should have a senior accountable officer who, knowing that he or she may be held publicly accountable, can speak the truth to colleagues when they are tempted to duck responsibility. It is an important principle of the way in which we have run public bodies that there is a senior accountable officer who can internally, as well as externally, give strong advice and leadership on propriety in the way that public money is spent. This amendment would ensure that the governing bodies of clinical commissioning groups had a person who could perform that function.
	Amendment 171 attempts to strengthen the provision on standards of governance for clinical commissioning groups in new Section 14L(2)(b). At present the Bill requires the governing board of clinical commissioning groups to have,
	"such generally accepted principles of good governance as are relevant to it".
	As I have said, clinical commissioning groups are a new kind of organisation, spending large sums of public money. There has been much debate about the adequacy of the Government's wraparound of these bodies. I share that concern and I believe that, as worded, the Bill does not go far enough. It tends to leave these groups to look around for a governance model that they deem to be relevant to them. They might find this a rather difficult proposition it its own right. There is a very strong likelihood that they will have very divergent governance arrangements for such large sums of public body money. We do not expect PCTs or local authorities to have that level of governance divergence in the way in which they conduct their affairs. That is why Amendment 171 attempts to increase the rigour and reduce the variation in the governance arrangements for clinical commissioning groups. It requires them to meet the standards of good governance of any elected or appointed public body authorised by Parliament. That seems to me to be the standard that we should be looking for, and we should expect these groups at least to be able to point to a governance system that is no worse than that of local authorities or PCTs.
	If this wording can be improved further, or if other noble Lords have ideas for improving that governance, I am happy to go along with any proposition that strengthens the Bill in its governance requirements and produces an outcome that is likely to mean less divergence between individual clinical commissioning groups in the type of governance that they produce for the running of their affairs.
	Amendment 174 has a different theme. It attempts to address the key issue of information that enables a public body, such as a clinical commissioning group, to discharge its public accountability in a way that enables comparisons to be made with other similar bodies within, in this case, the NHS. It is one thing to give clinical commissioning groups a lot of flexibility in the way in which they organise themselves. I see no reason why we should allow a thousand flowers to bloom in the way in which these groups choose to render public accounts for their work and expenditure decisions.
	I also struggle to see how the national Commissioning Board can itself review the performance of clinical commissioning groups without some template setting out how it would do so. It would not be able to shrug its shoulders when asked about groups perceived to be performing poorly. It will need some evidence that it can make public about that inadequate performance. Why should that evidence vary dramatically from clinical commissioning group to clinical commissioning group? If that is to be the case, we should be clear from the outset that there will be a more standardised system of minimum financial performance information that these groups are required to publish annually. That is in the interests not only of the good governance of these bodies but of the public understanding what they are getting for their money from those groups.
	It is critical that any such system has a good weighting of financial and cost data. Healthcare systems here and overseas are very good at putting into the public arena data about what they have produced that are often disconnected from how much they have cost to produce. We need a clear obligation in statute on the national Commissioning Board to require more data in this area from this rather diverse group of clinical commissioning groups.
	I lived through the process of dealing with financial meltdown in the NHS in 2005-06. One of the main causes of that meltdown was that the NHS could explain to hardly anybody collectively the relationship between the level of activity and the cost of that activity. It had two streams of data-one about money and one about activity-and they were not related to each other. If we repeat that approach in clinical commissioning groups, we will end up in the same place as we ended up in 2005-06.

Baroness Barker: I shall speak to Amendment 92ZZA, which stands in my name and those of my noble friends. At this time of night, brevity is of the essence. This amendment addresses a crucial point.
	The whole structure that the Bill sets up for the NHS depends on a number of things to work efficiently. It depends on the clarity of responsibilities and on different bodies having a clear understanding not only of their own role but of their role in relation to each other. One of the most important parts of the process underlying the structure is integrity. Although there has been much exaggeration about potential conflicts of interest in some of the things that I have seen, there is one-the one that I have highlighted in this amendment.
	One commendable thing about this Bill is that in relation to acute care and hospitals we are stopping the process by which organisations-in this case acute trusts-are rewarded for the volume of the procedures they do rather than the quality of their outputs. It is important in commissioning that we stick to that same principle. There must be no possibility whatever that anybody who is involved in the commissioning of services stands to gain by the provision of those services, or their volume. That is why I have drafted this amendment. It may be imperfect in some way or another but its intention is to say that those commissioning decisions must be completely separate from the derivation of any benefit-or pecuniary benefit-as a result of that.
	I have absolutely no problem whatever with people who either work for or are shareholders of commissioning support organisations advising CCGs on what to do. If they are, as we have been led to believe, experts in commissioning and clinical commissioning groups want to bring in their expert advice, that is absolutely fine. I do not have a problem with that at all, as it could be a much more efficient and effective way in which to do it. However, it would be unacceptable if those same people had any role whatever in the decision-making processes of the CCGs, either by being a member of a CCG board or by being a member of one of the CCG sub-committees. My amendment attempts to remove that potential conflict of interest. It is probably one that the Government had intended to remove, but they have not done so in the Bill as it stands, and so there is a loophole which needs to be closed in order that there is complete integrity about the process.

Baroness Finlay of Llandaff: My Lords, this group of amendments and this debate are incredibly important. The risk of conflict of interest relating to general practitioners is particularly high because they are independent contractors-they are not NHS employees and therefore are not answerable in the same structure as an NHS employee would be within an organisation. Independent contractor groups may be small or they may be as large as practices.
	I have been a GP myself and have had to go through the business of partnership agreements. I know only too well from colleagues of mine how disastrous the break-ups in partnership agreements can be and the degree of animosity that can occur. When we talk about GPs being on commissioning groups, there is a real problem in terms of how much they are going to get paid for undertaking commissioning decisions. If they are commissioned from an organisation with which they have a link-because they are a GP with a special interest and they work in another organisation-what are they being paid for? The content of their general and medical services contract is not closely defined. If they have a special interest, which their practice then refers to one of the partners in the group who is providing a service as part of another provider group, there is a risk that people in that practice will be getting double-paid under the organisation of that arrangement.
	To try to explore this, I telephoned Assura, a group which is providing dermatological services in an area. I tried to explore the situation with regard to their internal governance arrangements and commissioning arrangements if they have a GP working there and how those arrangements are monitored. I was reassured by what I was told by the person on the phone, who was most helpful. However, it did not take away my anxiety. This provider was being careful and making sure that clinical governance structures were in place, but I have not been able to understand where the controls are on a clinical commissioning group. Will they be only on people who are GP principals on it, or will they apply to all the doctors who are working in general practice? Where will the GPs sit if there are a small number of principals, a large number of salaried GPs in an area who are doing all the clinical work and who know what needs to be done, and a senior partner who is taking the profits out of the business which is the business of the general practice?
	Where coterminosity links to this is that, if you have coterminosity between the commissioning group and other services-local authority services, education services and so on-you at least have another organisation, or two others, which will be seeing what is happening. If you take a complex family-perhaps a single parent with one child with developmental delays, another with complex conditions such as epilepsy, diabetes or whatever, and another child who might be being neglected-then, by having triangulation between local authority services, education services and those services being commissioned, the gaps in the commissioning process may emerge. However, if you do not have coterminosity, I can see each group saying, "It falls outside our area", and the children or the patients will fall through the gaps. With regard to the commissioning group, poor decisions in commissioning or decisions which involve a conflict of interest may not be revealed for a very long time.
	Therefore, I urge the Government to look closely at these amendments, particularly the one tabled by my noble friend Lord Kakkar on the Nolan principles, because, unless we tighten up on the processes that will monitor and provide governance over the way that members of the clinical commissioning group behave, we run a risk. I wish that I could share the optimism of the noble Baroness, Lady Barker, that the conflict of interest will lie only among those supporting commissioning decisions, but I do not.

Lord Greaves: My Lords, this is a very mixed bag of amendments. It is all about clinical commissioning groups but the issues behind such a mixed group are varied and it is quite difficult to get a coherent debate about them-although I do not criticise the Government Whips' Office for attempting to push this Bill along a bit, given the speed it is going. I shall speak to three or four of these amendments. I totally agree with everything that my noble friend Lady Barker said, so I will say no more about that.
	The noble Lord, Lord Whitty, started us all off with Amendment 59A, suggesting that,
	"clinical commissioning groups ... coincide with local authority boundaries".
	In his speech, the noble Lord modified it a bit further than his amendment seems to go but the basic principle behind it is extremely important, except that where there are large, sprawling counties in two-tier areas those counties are clearly far too big to be the areas of the commissioning groups. In a county such as my own, Lancashire, or North Yorkshire it would seem sensible for the clinical commissioning groups to be smaller than the county, although I would argue strongly that the county boundaries and the top-tier or the unitary authority boundaries should not be crossed.

Lord Warner: Is the noble Lord aware that some of the most effective clinical commissioning in the existing arrangements has been done by primary care trusts which are based on county boundaries?

Lord Greaves: I am not saying that there are no counties where that might be the appropriate arrangement. I am saying that in very large counties which, first, have a large population and, secondly, cover a large geographical area it would be excessive. Indeed, the situation in those counties which I just referred to is that the primary care trusts do not cover the whole county. All I am asking for is a degree of flexibility to allow appropriately sized clinical commissioning groups where the counties themselves would be too large. I declare that my own county is one such example. Indeed, as I said earlier, the areas that people are looking at as being appropriate for CCGs in Lancashire do not cover the whole county but the principle is absolutely right.
	More important is Amendment 60, which is linked with Amendment 92ZZA, which my noble friend spoke to. Amendment 60 is about the code of conduct and was spoken to by the noble Lord, Lord Kakkar, and the noble Lord, Lord Patel, who I am pleased to see in his place again to hear what I have to say. As far as I am concerned, there is a real sense of déjà vu here, since in debating the recent Localism Bill-I do not know whether it is now the Localism Act-we spent many hours agonising over codes and standards of conduct for members of local authorities. I assume that when the noble Lord, Lord Kakkar, talks about a code of conduct applying to clinical commissioning groups he actually means that it applies to the members of those groups.
	I do not want to say a great deal more about this now, because if I start I will be difficult to put down. However, there was a great deal discussed during the Localism Bill since the Government started off with the position that they wanted to sweep away the existing regime in local government for local authority members, which is based on the Standards Boards for England and which they thought-and I agreed with them-was highly bureaucratic and expensive, very legalistic and over the top. They wanted effectively to remove the standards regime altogether. As a result of intensive discussions in your Lordships' House in Committee, on Report and at Third Reading, a compromise was arrived at-a lighter touch regime, which regrettably does not involve a national code of conduct but requires local authorities to have a standards regime, to adopt a code of conduct based on the Nolan principles and a published system which is transparent and applies to local authority members in their area. The two noble Lords putting this amendment forward might profitably spend an hour or two reading Hansardfrom the Localism Bill-I am sure they will enjoy doing so-and looking at the way it might be applied to clinical commissioning groups, different bodies but with the same principles. If they come back on Report to say what regime would be appropriate I am sure those of us who have been involved in the Localism Bill would be pleased to discuss it.
	Amendment 175CA is the first of what I believe to be extremely important amendments put forward by the noble Lord, Lord Hunt of Kings Heath. It refers to representatives of district councils in two-tier areas. This is important because district councils in two-tier areas have actually been written out of this Bill and not included under the various definitions of local authorities, despite having a very important role to play in public health; they are housing authorities, housing standards authorities and environmental health authorities, and they provide all sorts of public health facilities such as leisure services. At present they often work closely with their primary care trusts on local projects to improve public health. It is an important issue in this Bill that will come up again later so I will not say any more now.
	Direct representation on CCGs is not necessarily the most important issue here. If you have five or six district authorities in one CCG, as it looks like we will have, the representation would not be very direct anyhow. It is a crucial issue and one which casts its shadow over discussions we shall have in coming days. The really important parts of the amendment tabled by the noble Lord, Lord Hunt, are about the government structures, how many independent members there may be on the CCGs and what role they will have. This is absolutely fundamental and links with local accountability. Should local accountability be to the patients in the area? Should it be through GPs? Should there be an understanding of some kind of accountability to everybody who lives in the area covered by the CCG? It is becoming very clear indeed that they are going to be area-based organisations responsible for the health of people in their area, despite the fact that some of the GPs will have patients who cross boundaries.
	I think it was the noble Lord, Lord Hunt, who said that if it is simply left to the groups themselves to appoint their members and successors they will run into trouble. There are going to be many countervailing forces within this new complex system that we are to have at local level. Bringing those countervailing forces together might result in integration, but if there is not sufficient integration and accountability built into the system it will result in conflict. There will be all sorts of different bodies involved. People will be out on the streets campaigning and collecting petitions, and the general culture within the local NHS will too easily become one of conflict rather than of people working together for the best of the area. The composition of the commissioning groups, the way in which they work and their accountability are going to be absolutely fundamental to this. If, with the assistance of this House, the Government get it right, it could be very successful. If they get it wrong, we will all be back in two or three years trying to get a new system, and we really do not want to see that happen.

Lord Beecham: My Lords, when I spoke to the amendments concerning the NHS Commissioning Board, I said that the arrangements for governance, membership and the like were skeletal. In the absence of the most reverend Primate, I am probably safe to say that these arrangements for clinical commissioning groups are, by comparison, words made flesh. There is currently virtually nothing in the Bill that indicates how these commissioning groups would be constructed, what their membership would be and indeed what they should do.
	Clause 22 contains provisions to make changes to the 2006 Act to provide for regulations as to the governing bodies of clinical commissioning groups. It is disappointing that nearly a year after the Bill was first produced we are debating the formation of clinical commissioning groups without any clarity at all-for example, in the form of draft regulations, if they are to be prescribed by regulation rather than the Bill itself-about how these groups should be composed. It is quite unsatisfactory. Clearly tonight we are not going to be voting on anything-these are probing amendments-but I hope that before we get to Report we can have sight of draft regulations to see what is in the Government's mind and what changes might be necessary for the composition of these bodies. I have some sympathy with Amendment 101A, tabled by the noble Baroness, Lady Williams, but that assumes that it would be the function of the NHS Commissioning Board to ensure the composition of the commissioning groups. That does not necessarily follow and presumably we will not know until we see what the draft regulations contain.
	A number of your Lordships have referred to the issue of coterminosity. In principle, it sounds fairly straightforward although in practice it looks a little less straightforward. There are different types of coterminosity. As I have said before, in my home town of Newcastle we have two clinical commissioning groups. In one sense they are coterminous because they are within the boundary, but on the other hand there are two of them. What if they do not agree? What if there are competing, conflicting ideas about what should be commissioned from the service in Newcastle? That assumes that you can treat the services within the city as confined to the city, but of course that is not the case. There are facilities in the city that are widely used across the region. Some of them are specifically regional centres. It may be that some of these services would be commissioned by the NHS Commissioning Board, but others would not. In this era of patient choice and the like-and one understands and supports that-there will be interest from other commissioning groups around the region in what goes on in the city, so coterminosity takes on a different flavour in that respect. In some parts of the country geography could make it difficult to envisage coterminosity. In a county like Cornwall or Devon, commissioning groups based primarily on general practitioners would be less likely to find it easy to work on the basis of coterminosity across the county area.
	In previous debates the Minister referred to the possibility of groups working together. This needs to be fostered. It may be that the commissioning board would have a role in that, or this matter could be covered by regulations to provide for the opportunity for groups to cluster effectively to replicate the pattern of primary care trusts. As matters stand, however, it does not seem that is likely.
	There are issues of a different kind about coterminosity because some, in particular GP consortia, may have interests in different areas. The Haxby Group in York, which has been mentioned in your Lordships' House before-the general practitioners' group which on NHS-headed paper advertised effectively a private service, though that is not the point I am making-also operates in Hull. That is in a different area. Hull is a unitary authority and York, which is also a unitary authority, is in North Yorkshire. They are two quite distinct areas. The practice, however, operates in both. I am not sure how a practice like that fits into the scheme of commissioning groups. Will it be present on two commissioning groups? Maybe and maybe not. Maybe it creates a difficulty; maybe it does not. It needs looking into.
	I agree with the noble Lord, Lord Greaves, in commending my noble friend Lord Hunt's proposals around some district council representation. We will revert to this later when we are talking about health and well-being boards, where there is a more obvious role. Nevertheless, there is a potential role for district councils, with the services and responsibilities to which both noble Lords have referred, to have some place in commissioning groups. There is certainly, judging by the tenor of the previous debate, a clear role for either the director of public health or at least his or her representative to sit on commissioning groups. Again, if there is simple coterminosity-one local authority and one commissioning group-there is no problem. If you have, however, a number of commissioning groups within the area served by a principal authority, with someone running around from one group to another, it would not work but they could be represented. That should be looked at.
	There seem to be a number of unanswered questions and this late in the day, in every sense, we cannot take them much further tonight. I hope, however, that the Minister can assure us that there will be an opportunity to have draft regulations and responses to all the issues that have been raised tonight in good time for the House, which has different concerns across the divide here, to consider them carefully, in order that we can take a clear view about how to close the gaps in the Bill on the basis of clear proposals expressed where necessary in the form of the draft regulations which will apparently be heading our way at some indefinite point in the future.

Baroness Jolly: My Lords, I think I am the last Member of the Committee to speak on the amendments in this group and I promise I will be brief.
	I have two amendments in this group. One concerns a public health specialist on the clinical commissioning groups. We have been around the houses with this and my noble friend Lady Williams has spoken most eloquently on this matter so I will not emphasise the points again. My second amendment is to do with the recruitment and remuneration of lay members of clinical commissioning groups. The Committee has rehearsed the arguments that there is a lot of silence around clinical commissioning groups and their governance. This just underpins that. There is a bit of a Catch-22 with this situation because the Bill makes provision for an audit committee and a remuneration committee and also for a lay member to chair each of the two groups. Therefore, you could argue that a remuneration committee might play a part in deciding how much a lay person would be remunerated by for sitting on the group. However, we do not yet have the lay person to chair the group and take the decision, so who will take the first decision about the appointment of these two lay members? They will also need remuneration; who will take that decision?
	The other big issue that has been discussed by the Committee this evening is that of transparency within the governance of clinical commissioning groups. I expect the noble Earl hopes to wind up soon. When he does, I hope he will be able to give us a steer on the Government's thinking on this.

Baroness Armstrong of Hill Top: Briefly, this is a very important set of amendments, which we do not have time to deal with effectively in the next 10 minutes. I understand that the Government do not want to spend more money. Indeed, the Minister said earlier that the whole idea was to cut down the amount of money spent on CCGs, relative to what was previously spent on PCTs. The problem is that there will be more CCGs than there are PCTs and there is deep anxiety over the lack of clear governance. The Government have a problem here. So far we have had clues that there is to be accountability upwards. These amendments make it clear that there must be accountability downwards, too.
	As the noble Baroness, Lady Finlay, said, GP groups are different from other groups in the National Health Service. They are not used to this level of accountability or this level of governance-even at the level that the Government have already put into the Bill. Nobody outside, particularly in other aspects of the NHS, thinks that the governance in the Bill is adequate. I share the concerns that other people have expressed tonight; I share the concerns about co-terminosity.
	I have mentioned previously to the Minister that Durham is now a unitary county. We used to have seven PCTs in Durham and Darlington; we now have one. We will have three CCGs. I do not believe that that will be cheaper and I am not yet convinced that it will be more effective for commissioning. The Government have a lot to do to reassure people that this will be more effective and that it will be accountable. There are many GPs who are now anxious the other way around. They are anxious that if they go into CCGs, the level of accountability, governance and bureaucracy will be so great that they are saying, "We're not sure we want to have anything to do with it".
	This is an area where I suspect the Government will say that, in all truth, this is not where they want to be. However, this is where we are and the responses that we have heard so far simply do not meet the level of anxiety and the need for accountability that everyone thinks is there.

Lord Davies of Stamford: My Lords, what I want to say might have been a little long as an intervention in the Minister's speech but it will be very short as a speech. I simply want to ask the noble Earl, when he replies to this debate, to address in a considered way how the Government intend to deal with an enormously significant and worrying conflict of professional interest that could arise in this context. Anyone who is a member of a clinical commissioning group, whether he or she is a GP or not, must presumably be committed and signed up to the priorities, policies and plans of that clinical commissioning group. However, where that individual is also a GP who has his or her own patients, some of those patients may have conditions that do not get a very high priority in those plans and policies. Surely there is an immediate conflict of interest. In the present circumstances, the GP can say to his or her patient: "I am doing my best to battle with the PCT to get the treatment that I really think you need". However, in the situation that arises as a result of the structure in this Bill, that GP would be on both sides of the table. He would be arguing with himself and making representations to himself. Surely the noble Earl would agree that it is a thoroughly unsatisfactory situation. Can he assure the Committee that it will not arise and, if it does, that the Government have a clear set of rules or procedures for dealing with it?

Earl Howe: My Lords, we have had another well informed and stimulating debate. I will start by going back to the beginning. On paper, clinical commissioning groups can seem like a dry concept, but I would encourage your Lordships to look beyond the words and duties on the page and consider what CCGs will be able to achieve in practice. GPs and other front-line professionals already make the clinical decisions that determine how most NHS resources are used. Putting them in charge of shaping services will enable NHS funding to be spent effectively to provide high-quality care.
	I have seen at first hand the work of primary care clinicians-GPs, nurses, allied health professionals and others-in leading the commissioning of services. I have been struck on numerous occasions by their dynamism, innovation and their absolute dedication to ensuring that their patients receive high quality care. It is in that context that we should consider our debates on this topic, including this one, which have focused primarily on ensuring that CCGs have effective governance arrangements, but have also touched upon CCG boundaries.
	I do not agree with the noble Baroness, Lady Armstrong, that the arrangements are weak. We have already responded to the Future Forum's recommendation to strengthen the Government's arrangements for CCGs and made it a requirement for every CCG to have a governing body. We recognise that good governance will be critical to the design and operation of CCGs, in order that they act transparently, manage conflicts of interest and have the proper checks and balances in place to provide assurance that decisions are taken in ways that protect patients' best interests, promote continual improvements in quality and provide assurance that public money is well spent.
	That is why I believe that the Bill already achieves the intent of Amendment 60, which would place the Secretary of State under a duty to publish a code of conduct for CCGs, incorporating the Nolan principles on public life. I am fully in support of CCGs adhering to the principles established by the Committee on Standards in Public Life. However, new Section 14L already states that the main function of a governing body of a CCG includes ensuring that the group complies-and these were the words quoted by the noble Lord, Lord Warner-
	"with such generally accepted principles of good governance as are relevant to it".
	The Nolan principles, or any successor principles which the Committee on Standards in Public Life or another body was to issue, would be foremost among these. However, the provision in the Bill will also encompass any other relevant, generally accepted principles of good governance issued by appropriate bodies, such as the Institute of Good Governance, and therefore has the potential to be of wider effect. That is why I feel that Amendment 171 is also unnecessary, as it appreciably narrows the field of vision of the governing body.
	In addition, the Bill already sets out other provisions which relate to a CCG's conduct. For example, with respect to the constitution of a CCG, the constitution must include arrangements for ensuring absolute transparency. It must specify the arrangements for discharging the CCG's functions, its decision-making process, how it will secure transparency about the decisions of the group, and how it will deal with conflicts of interest of members and employees of the CCG or members of the governing body.
	Amendment 174 clearly aims to ensure transparency around the performance of a CCG in terms of its financial management and the outcomes that it secures for its patients, by requiring the NHS Commissioning Board to specify minimum standards of financial and performance information to be published annually by all CCGs. I say to the noble Lord, Lord Warner, that this is already provided for. Under new Section 14Z13, to be inserted in the NHS Act 2006 by Clause 23, CCGs are already subject to a duty to prepare and publish an annual report on how they have discharged their functions in the previous financial year, and the report must explain how the group has discharged its duty as to improvement in quality of services. The Bill also requires each CCG-

Lord Warner: I am sorry to interrupt the noble Earl, but I was aware of that. My concern was that it seemed to leave to clinical commissioning groups the decision on what type of information they put in that. They could put in a whole load of information that was not comparable with any other clinical commissioning group. The whole point of my amendment was that there should be a level of standardisation so that we could see the different levels of performance in different CCGs.

Earl Howe: My Lords, I take that point on board. It is my understanding that the NHS Commissioning Board will wish to set common standards for CCGs to follow. However, I will follow up that point with the noble Lord. As I said, the Bill requires each CCG to prepare annual accounts, independently audited. The board may, with the approval of the Secretary of State, direct CCGs as to the methods and principles according to which their accounts must be prepared, and the form and content of such accounts. Therefore, there will be scope for the board to drive consistency in the area the noble Lord mentions.
	I turn now to Amendments 169, 175BA, 175C and 101A, which concern membership of, and appointments to, CCG governing bodies. In response to mendment 169, as the Bill stands, under new Section 14N, regulations may already provide that members of governing bodies must include the accountable officer of the CCG. Paragraph 11 of Schedule 1A also specifies that the accountable officer may be one of the following: a member of the CCG, or an employee of the CCG or any member of the group. Restricting the accountable officer to being the "most suitable senior employee" of the group, as Amendment 169 also proposes, would narrow who the officer could be and ignore other able candidates, so I am not attracted to that amendment.
	Amendment 175BA, and Amendments 175A and 175B, which we will be discussing in more detail in a future group, clearly intend to ensure CCGs have access to professional or other expertise to advise on all areas of their work. This is undoubtedly important, but the governing body is not the route to achieve this. As the Future Forum advised, a clear distinction should be made between governance of CCGs and clinical involvement in designing care pathways and shaping local services.
	Clinical involvement in designing pathways or shaping services is exactly what a CCG will need to ensure in exercising its duty in new Section 14V, which requires a CCG to obtain advice appropriate for enabling it effectively to discharge its functions from individuals, who, taken together, have a broad range of professional expertise.
	Clinical senates and networks will, of course, be crucial to effectively meeting this duty and to ensuring that CCGs can access specialised advice, as will the local knowledge and public health knowledge held by health and well-being boards. We believe there is a case for ensuring that governing bodies include the voices of some other professionals-at least one registered nurse and a secondary care specialist-but it would be unhelpful, as the Future Forum also acknowledged, for governing bodies to be representative of each group. That could lead to bodies that are too large and slow to do their job well. CCGs should have the flexibility to determine the professional input into their governance arrangements.
	Amendment 175C would provide for regulations to be made setting out how lay members are recruited and remunerated. Subsection (3) of new Section 14N already makes provisions as to the appointment of members, including lay members, to the governing body. Paragraph 12 of Schedule 1A allows the CCG to pay members of its governing body such remuneration and other expenses as it considers appropriate. These existing provisions cover the intent of Amendment 175C.

Lord Hunt of Kings Heath: My Lords, can the noble Earl assure me that the appointments will be made by independent bodies, and that it will not be a case of the board of the CCG making the appointments to itself? In terms of corporate governance, can he also assure me that non-executives will be in a majority as they are on every public body which the Government have recently enacted?

Earl Howe: If the noble Lord will allow me, I will answer those questions in a moment. Amendment 101A would similarly duplicate existing provision by placing a duty on the NHS Commissioning Board to ensure that all CCG governing bodies meet the requirements for clinical and non-clinical representation. The board already has to do this; under proposed new Section 14C, the board can grant an application only if it is satisfied that the applicant CCG has made appropriate arrangements to ensure that the group will have a governing body which satisfies any requirements imposed by or under the Act. That would include regulations made under proposed new Section 14N providing for minimum levels of clinical and lay representation.
	Amendments 170A, 175D, 175CA and 175CB seek to introduce alternative governance arrangements for CCGs. These amendments would remove the existing functions of the CCG governing body and, through the proposed new schedule, replace the governing body with both a board of directors and a board of governors. I was grateful to the noble Lord for explaining where this idea originated. However, the amendments do not propose functions for these boards to exercise. They concentrate almost solely on the form of CCG governance; they neglect the function. As to that form, there is much here which is already provided for in the Bill and in relation to a governing body. I should perhaps explain that our preferred approach is to set through regulations the key requirements in relation to the composition of the CCG governing body and the logistics of their qualification, appointment, tenure and so on. This will, most importantly, allow flexibility for the approach to evolve over time and in the light of experience.
	Turning to Amendment 59A on the subject of the area covered by CCGs, in the light of our lengthy debate on this last week, a letter will shortly reach your Lordships to provide further information on the arrangements for geographic areas of CCGs. It includes some analysis of the key issues which I hope will be useful and reassuring. We accepted the Future Forum recommendation that the boundaries of CCGs should not normally cross those of local authorities. If a CCG wishes to be established on the basis of boundaries that will cross local authority boundaries, it will be expected to demonstrate to the NHS Commissioning Board a clear rationale in terms of benefits for patients; for example, to reflect local patient flows and to secure a better service for patients. The board will also be required to seek the views of emerging health and well-being boards. In addition, CCGs will have the flexibility to enter into lead or joint commissioning arrangements with other CCGs; for example, for commissioning of lower volume or more specialist services. I hope that this reassurance will satisfy the noble Lord's concerns.
	Finally, Amendment 92ZZA seeks to mandate the Secretary of State to make regulations imposing a ban on shareholders and employees of commissioning support organisations being given a seat on a CCG committee or governing body of a CCG-I assume that it is the governing body that the amendment refers to rather than the NHS Commissioning Board. We agree that there should be no conflicts of interest between a CCG and any commissioning support organisation that it uses. The support offered by such organisations should inform decisions made by CCGs, but we have always been clear that CCGs cannot delegate their duties or responsibilities. However, such an absolute ban would not take into account situations, for example, where a CCG may wish to invite individual employees from commissioning support organisations to provide expertise on a committee. The Bill already requires CCGs to have robust provision for managing conflicts of interest in how they discharge their functions.
	It is clear from the debate that these amendments were proposed with the best of intentions, but I hope that noble Lords will feel that the points that I have made are sufficiently compelling to encourage them not to press the amendments.
	I have a few questions that I would like to answer briefly. The noble Lord, Lord Hunt, suggested that the chair and deputy chairs of CCGs should be lay members. Each CCG must have at least two lay members. We are specifying that, and we have committed that one of the lay members of CCGs will be either the chair or the deputy chair of the governing body.
	The noble Lord, Lord Rea, asked me how a CCG's geographic area would be determined. The primary factor in establishing the CCG's boundaries or geographic area would be the practices that made up the membership of the CCG. The NHS Commissioning Board must satisfy itself that the proposed area for a CCG is appropriate and that the CCG can commission effectively for that area. That is a very condensed explanation of what the Commissioning Board will be looking for.
	The noble Lord, Lord Hunt, suggested that he could not understand how CCGs would be accountable. Accountability is a key area. There is no doubt about that and I share the noble Lord's desire to get this right. We listened to the Future Forum when it said that there is a balance to be struck between the need for good governance and the need to avoid overprescription. Perhaps that is a generally accepted principle-I certainly agree with that. I think the amendment of the noble Lord, Lord Hunt, goes too far. However, we are absolutely clear that CCGs will be materially accountable in a number of ways. I could recite a number of ways that I have in front of me, but at this hour it might be appropriate for the noble Lord to receive that in writing from me. I would be happy to do that and to copy it round.
	On the subject of conflicts of interest, we will be having a very full debate in the context of Clause 20 on conflicts of interest. I have a lot of material here, but essentially there are principally three safeguards in the Bill to prevent conflicts of interest: statutory requirements on clinical commissioning groups to have in place arrangements to manage those conflicts of interest-those have got to be set out in the group constitution; secondly, strengthened governance arrangements as regards the governing body, and I briefly outlined those; and specific provision for regulations to require that the board and the clinical commissioning groups adhere to good practice in relation to procurement and in commissioning healthcare services.
	My noble friend Lady Jolly asked who will appoint members of the clinical commissioning group boards. We will work with patient and professional groups and with emerging clinical commissioning groups to determine the best arrangements for appointing members of governing bodies. As I have indicated, the Government will issue regulations in due course, setting out in more detail the requirements for appointing non-GP members to the governing body.
	The noble Lord, Lord Hunt, asked whether non-executives would be in the majority on boards. I am not currently able to give that assurance. We are still working with a wide range of stakeholders on the regulations for governing bodies. We are well aware of concerns in this area. I will take the noble Lord's points very firmly on board.
	Very briefly in this group, I would also like to speak to government Amendments 172, 173 and 175, which are minor and technical in nature. Amendment 172 clarifies that the remuneration committee of the CCG governing body has the function of making recommendations to the governing body on its determination of allowances payable under a pension scheme established by the CCG for its employees under paragraph 10(4) of Schedule 1A. Government Amendment 172 allows regulations made under new Section 14L(6) to make provision requiring CCGs to publish prescribed information relating to determinations of the allowances payable under a pension scheme. Government Amendment 173 makes provision for the board to publish guidance for governing bodies on the exercise of this function. I trust the Committee will join me in supporting these minor and technical amendments.

Lord Whitty: My Lords, I thank the Minister for that detailed reply to what has been a fascinating debate. I fear, however, that he will have to return to a number of these issues.
	The issues of accountability, governance, conflicts of interest and transparency are about confidence in the new system-not only confidence in this House but confidence in the population. The issue of coterminosity-which I thought was a word I had invented but I am glad that others took it up-is also vital to that because people understand the county boundary and where the services are and that there is a relationship between them. I am grateful for the Minister's offer of a letter on the geographic boundaries but, before we complete the consideration of the Bill, we will have to be clear what the relationship between local authorities, providers of social services, those responsible for public and environmental health and the new CCGs is going to be. That also is an issue of confidence and understanding by the population and the people who use the health service.
	Having said that at this hour of the night-I note the Chief Whip's impatience-I beg leave to withdraw the amendment.
	Amendment 59A withdrawn.
	Amendment 60 not moved.
	House resumed.

House adjourned at 11.17 pm.